Inspection on 25/05/07 for The Old Vicarage

This inspection was carried out on 25th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Vicarage 15/06/06

The Old Vicarage 05/12/05

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Old Vicarage Vicarage Lane Tilmanstone Deal Kent CT14 0JG Lead Inspector Chris Woolf Key Unannounced Inspection 25th May 2007 08:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Vicarage Lane Tilmanstone Deal Kent CT14 0JG 020 8462 1870 01304 615323 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Pathmanathan Elango Mrs Rajakala Elango Mrs Janet Swanborough Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users with a learning disability to be restricted to two (2) whose DOB are 21/05/1936 and 22/10/1935. Service user with a diagnosis of dementia DE (E) to be restricted to two with dates of birth 15/11/1913 and 31/06/1920. 15th June 2006 Date of last inspection Brief Description of the Service: The Old Vicarage provides residential care for 39 older people; this includes 2 with dementia and 2 with Learning Difficulties. An application is currently being considered for the home to accept more clients with dementia. The Home comprises a large, extended detached house located in a rural area between the coastal towns of Dover and Deal. There is a shaft lift to provide access to most of the first floor but there are still 6 steps to access the rooms on the mid floor. Six of the bedrooms have en suite facilities. There are spacious well-maintained garden areas including a pond where residents enjoy sitting in the better weather. Other facilities such as hospital, shops library, theatres etc are within a fifteen minutes drive and the Home has an appropriately adapted minibus. The current fees for the service at the time of the visit range from £312.81 to £410.00 per week. Information on the Homes services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. There is no e-mail address of the home currently available. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information received in an annual quality assurance assessment completed by the home, questionnaires received from 1 service user, 1 relative, and 2 health care professionals, and an unannounced site visit to the home which lasted just over 7 hours. The site visit included talking with a variety of service users, 4 in some depth, several visitors, the manager, and several members of staff; observing the interaction between service users and staff, a meal being served, a craft session taking place, and medication being administered; a tour of the home and gardens; and examination of a variety of records. What the service does well: The manager and a dedicated staff team look after the health and welfare of service users, and encourage them to join in a variety of activities. A service user commented, “they meet my needs, they are very good”. A visitor commented, “The care she has received here is second to none”. Meals at the home are of a good standard. A service user comment card stated, ‘the food is very good and to a very high standard’. Assessments and care plans are holistic and comprehensive and service users or their representatives are involved in reviews. The grounds are attractive and well maintained. Health professional comment cards included ‘Good supportive environment’. ‘Home very clean and attractive’, and ‘Pleasant surroundings with good general care’. A visitor comment card included ‘They seem to do their best to provide a safe and good quality home’. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that their needs will be assessed prior to moving into the home. EVIDENCE: A Service user’s comment card confirmed that sufficient information had been received before the service user moved in, and included the comment, ‘Very impressed with the manager who gave us confidence that this was the right home’. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 10 Each service user is issued with a contract stating the terms and conditions of residence in the home. A signed copy of each contract is kept securely in the home. Prior to the admission of any new service user the manager carries out a comprehensive pre-admission assessment. These assessments are holistic and contain sufficient information to form the basis of a plan of care. Where service users are care managed a copy of the joint assessment is also received. A comment was seen on paperwork held in the home, praising the comprehensive assessment. The home currently caters for two service users with learning difficulties and two with dementia. The provider has now applied for an application for variation of registration to enable the home to accept additional service users who are suffering from dementia. In preparation for this variation staff have received dementia training, and environmental adaptations have been made to ensure service users security. This home does not offer the facility of intermediate care. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and personal care needs are be met by the home supported by the multi-disciplinary health care team. Service users are treated with dignity and their right to privacy is upheld. EVIDENCE: A comprehensive and holistic care plan is in place for each service user. These plans include a variety of risk assessments and details of contact with health care professionals. Care plans are reviewed regularly and service users or their representatives are invited to participate in the review process. The manager has agreed to include the date of admission on all care plans. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 12 Service users’ health care needs are met by the home, supported by a multidisciplinary team of health care professionals. Visiting professionals spoken to commented, “The care is very good, residents come first, there is a high level of personal hygiene and general care”, and “The care is good”. A record is maintained of personal care given to service users, although the gaps in recording could give a false picture, and all staff need to be aware of the importance of clear and accurate documentation. Any concerns about pressure areas are notified immediately to the district nurses who give treatment, support, advice, and supply the necessary equipment for maintenance of tissue viability. A professional comment card included the comment, ‘Good skin care regimes’. Weights are recorded regularly and any significant variation is investigated. Specialist doctor, district nurse, chiropodist, optician, and dentist visits are arranged as necessary. Service users said, “They look after me well”, and “We are well looked after, particularly if ill”. Visitors commented, “The care she has received here is second to none”, and “They were very caring when her eyesight went”. Comment cards also confirmed that the level of care is good. One staff member suggested that a key worker system would benefit service users and staff. The home has changed their medication provider and now uses a monitored dosage system for the handling of their medication. The recording of the receipt, administration, and disposal of medication is sufficient to enable an audit trail to be undertaken, and includes recording of carried forward medication. The administration of medication is handled sensitively. Storage of medication is in order, and since the last inspection a new drugs fridge with has been purchased. Homely remedies are approved by the relevant G.P prior to administration. Service users’ privacy and dignity are upheld and this was confirmed by professional comment cards, service users, visitors, staff, and through observation. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users continue to lead a varied and interesting lifestyle with choices in all aspects of their lives; their visitors are made welcome; they receive appetising and nutritious meals. EVIDENCE: The home has a varied activities programme in place for service users ranging from keep fit to cake decorating and pat dogs to musical entertainers. The home has arranged for a local artist to visit weekly to spend time with two service users who are interested in drawing and painting. The range of individual activities has been enhanced by the recent appointment of an activities coordinator, and one to one sessions are now available. An adapted mini bus is available for outings and for visits to the hospital when needed. On the day of the inspection a visiting craft organiser was helping service users to The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 14 make a patchwork collage of paintings. Staff on duty enjoyed joining in to help with this activity and to give service users 1:1 attention. The service users work was displayed in the conservatory at the end of the session. Service users comments included, “When I’m in I do activities”, “Activities are very good here, music, shows, crafts, exercises on Thursday, and music and lunch with families invited,” “They have people to sing at times” and “I join in the activities. One of the Residents likes to play cards and I play with her”. A visitor said, “There are enough activities. They had a choir here and we were invited”. The local vicar visits the home to administer Holy Communion, and other denominations are encouraged to visit. The home will support any service user who wishes to practise their religious beliefs, whatever these may be. Families and friends are welcomed into the home. Visitors commented, “They make you so welcome”, “I come at all different times”, and “I can visit when I like”. Contact with the outside community will be increased as the home has indicated that they are planning to take service users out at least twice a month for country drives; and to allocate time for the manager and staff to take service users out to restaurants, pubs, theatres and places of interest. Service users and staff confirmed that service users are given choices in all aspects of their daily lives. Service users, or their families or powers of attorney, deal with their own financial affairs. They are able to bring some of their own personal belongings into the home with them to personalise their rooms to their own taste. The home has two cooks who produce nutritious, balanced and well-presented meals. The cook of the day visits all service users each morning to check their choice of meals for the day. Service users said, “I have no complaint with the food, we get good portions”, “The food is pretty good”, and “The food is very good”. Visitors commented, “Mum always says the meals are good”, and “I am pleased that she has put on weight since being here”. Staff also feel the food is good and said, “The meals are excellent, lovely food”, “The meals are very good, more choices than previously”, and “The food is very good”. Service users who need assistance at mealtimes are helped sensitively. Specialist plates are available when needed to avoid food falling over the edge. Liquidised food is served in separate portions to give the appearance of a regular meal. Currently the home provides diabetic food where necessary but no other specialist, ethnic or cultural diet required. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their concerns will be listened to and acted upon and that they will be protected from abuse. EVIDENCE: The home has a simple and clear complaints procedure and a copy is on display in the hallway for easy access of service users and visitors. There has been one complaint since the last inspection, this was substantiated and has since been resolved. The recording of complaints is satisfactory and includes outcomes. Service users confirmed that they would know who to speak to with any concerns and commented, “If Janet can sort things she will”, and “There is nothing to find fault with”. The home has clear policies on abuse and whistleblowing and staff are all made aware of these during induction. The manager is an adult protection trainer and all members of staff have been trained in adult protection. Staff confirmed that they knew the procedure should they have any fears that abuse The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 16 was taking place within the home. A copy of the Kent and Medway adult protection protocols is available in the home. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is in need of maintenance and refurbishment to enable service users to live in a clean, comfortable and well-maintained environment. EVIDENCE: Although the location and layout of the home is suitable for purpose there are some areas of maintenance that need addressing as the home looks dowdy and unkempt in some areas. The ceiling blinds in the conservatory looked dirty on the day of the inspection site visit and the provider has subsequently obtained quotes for the replacement of these. Windows throughout the home were also dirty and desperately in need of regular cleaning and the provider The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 18 has now taken up a contract for a regular window cleaner.. There are areas in the home where the wallpaper, particularly the borders are coming away from the wall and this adds to the uncared for appearance. The providers have indicated that they intend to pursue a planned programme of maintenance and redecoration and a recommendation, rather than a requirement, has been made to reflect this stated intention. Since the last inspection The 2 lounges plus 5 bedrooms have been decorated. Staff commented, “The décor needs attention”, and “There are some decoration needs but the owners have had a lot of expenses since they took over. The 2 lounges and several of the bedrooms have been decorated”. A new central heating system is in the process of being installed. There is a shaft lift to provide access to the first floor. However there are still 6 steps to reach the rooms on the mid floor and service users who live in these rooms need to have the necessary mobility to manage these stairs. Additional security measures have been put in place in the home. The grounds are attractive and well maintained and there are various sitting areas dotted around for service users to enjoy the fresh air and sunshine. One resident said, “I love to sit in the sun”. Currently fences are being erected to make the garden more secure for the proposed service users with dementia. However, the manager has made the assurance that there will be gates to enable the other service users to access the remainder of the garden area as they can at present. Some rubbish was stored in one outside area but this was in the process of being removed and cleared. Communal areas in the home consist of two lounges and a conservatory on the ground floor and one quiet lounge on the first floor. A service user comment card included ‘The lounge has been decorated since my arrival’. The quiet lounge needs new furniture but provision of this has already been planned for in the development plan. Although many of the service users bedrooms have less than 12sq metres usable floor-space this is reflected in the homes statement of purpose. 6 bedrooms are fitted with en-suite toilet facilities. A service user said, “I’ve got a toilet in my bedroom”. Rooms are decorated and personalised to meet service users needs. All double rooms have screens available to ensure that personal hygiene tasks can be carried out in private. Service users commented, “I am on my third room, my choice”, “the room is quite good”, and “I would like to be on the ground floor, I don’t like the lift”. The home is generally clean and odour free. The existing cleaners make a good attempt at keeping everything up to date but it would be beneficial if there were a cleaner on duty every day. Service users commented, “The cleanliness is fairly good”, and “The cleanliness is very good”. Visitors said, “No odours”, “The cleanliness is acceptable”, and “Very, very occasional odour but not in the last few months”. Staff comments included, “The night staff The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 19 clean the lounges”, “Some days we don’t have a cleaner”, and “The cleaners try hard”. A requirement about staffing levels has been made under the staffing section of this report and the manager must consider domestic hours as well as care hours in her calculations. The manager is a trainer in Infection Control and staff have received infection control training. One staff member has attended a 2-day infection control training at Kent & Canterbury hospital. Appropriate infection control procedures are in place. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although staff recruitment and training is good, insufficient staff on duty could put service users at risk. EVIDENCE: Although they feel that service users are well looked after, service users, visitors, and staff all feel that there is insufficient staff on duty at all times to fully meet the needs of the service users. Service users comments varied from, “There are enough staff”, to “There are not enough staff on duty, particularly at night” and “I keep asking to be taken out but everyone says ‘in a minute’, they are obviously to busy”. Staff commented, “There are not always enough staff”, “The staff are very conscientious, there are just not enough of them”, “I like it here, but there is a lack of staff”, “I hope we are going to have more staff”, and “There are not always enough staff on duty”. A requirement is made that staffing levels must increase in order to fully meet the needs of the service users. These levels will need to be kept under The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 21 constant review, particularly once the home has a greater percentage of service users with dementia. The home has arranged accommodation for staff from India giving better flexibility to cover staff sickness and holiday cover Currently just over 41 of care staff have NVQ level 2 or above with a further 6 undertaking the training this will rise to over 57 . Further staff are waiting to do this training once the current group get towards the end of their training. A staff member commented, “I have done NVQ 2 & 3” The home operates sound recruitment procedures. No new member of staff is employed until 2 satisfactory references and a check against the Protection of Vulnerable Adults Register have been received. Staff files have been updated to reflect up to date requirements. Staff training has increased since the last inspection. All new members of staff receive induction to Skills for Care specification. Mandatory training, and training in dementia and adult protection is either up to date or booked, and an Alzheimer’s course is planned. The deputy manager is a moving and handling trainer. The manager is a trainer in adult protection, food hygiene, and infection control and this enables training to be held ‘in house’. Staff commented, “I have had dementia training”, “We are doing well on training and getting up to date”, and “I am soon due for an update on my trainers certificates in moving and handling and infection control”. General comments about staff included service users who said, “The staff are very good”, and a comment card that stated, ‘The staff are very helpful although I think they are short staffed’. Visitors commented, “I get on well with the staff”, “The staff are polite and helpful”, “The Staff are generally very good”, and “The staff are pleasant and helpful”. Comments from the staff team included, “I like working here”, “I enjoy it”, “I would like to have more responsibility”, and “I enjoy working here”. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the service users. The health, safety and welfare of service users and staff are supported. EVIDENCE: The manager has been running The Old Vicarage for many years now and has gained the appropriate qualifications. A deputy, and a dedicated staff team support the manager in her role. The manager and her deputy operate an on call system with one or other of them being available at all times. The The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 23 manager holds current certificates to train staff in Food Hygiene, Protection of Vulnerable Adults, and Infection Control. Residents said, “The manager is very good”, and “Janet works too hard”. Visitors commented, “A well run home”, “The management is very good, always watchful”, and “the manager is a gem”. Staff confirmed that they receive support from the manager and her deputy, and their comments included, “The manager is efficient in running the home and is conscientious”, “Janet works very hard”, and “Janet gives us support”. There was also a comment from a staff member, “We get support from the owners”. The manager spends a lot of time working in the home and is very visible although this can sometimes be to the detriment of important paperwork. The manager has developed a system of quality assurance. Currently questionnaires are circulated to Service users and their families. However the questionnaires are very basic and include some questions that are irrelevant in judging the quality of service provided by the home. A discussion has been held with the manager about expanding the questionnaire and also suggesting questionnaires are also sent to other stakeholders. The responsible person makes regular visits to quality monitor the home and provides a report of these visits. The manager carries out various audits on a fairly regular basis, however these are not all documented. A requirement has therefore been made that the quality assurance system is further developed to include more relevant questions for service users and their representatives; questionnaires to other stakeholders; and to formally document all audits. It is the policy of the home not to handle any service users finances. All services for hairdressing, chiropody and other personal items purchased are itemised on a monthly invoice and this is sent to the service user or their next of kin or power of attorney as agreed. Staff supervisions have increased since the last inspection but are still not formally recorded. The manager has given an assurance that formal, documented supervisions will take place for care staff at least 6 times a year. The health, safety and welfare of service users and staff are supported by the home. All staff are up to date or booked to attend the mandatory health and safety related training. Having an in house trainer for moving and handling, infection control, and basic food hygiene helps this. Health and safety records examined are all up to date and relevant. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18 (1) (a) Requirement Staffing levels must increase in order to fully meet the needs of the service users. These levels will need to be kept under constant review, particularly when the home has a greater percentage of service users with dementia. The homes quality assurance system must be further developed to include more relevant questions to service users and their representatives, questionnaires to other stakeholders, and to formally document all audits Timescale for action 30/06/07 2 OP33 24 (1) & (5) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 26 1 OP19 The planned programme of maintenance should be pursued to ensure that service users can live in a home that is comfortable and well maintained. The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Vicarage DS0000064625.V337754.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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