Inspection on 27/06/07 for The Old Vicarage

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Vicarage 04/07/06

The Old Vicarage 07/11/05

The Old Vicarage 19/07/05

The Old Vicarage 24/02/05

The Old Vicarage 01/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Old Vicarage (The) Market Place Riddings Alfreton Derbyshire DE55 4BQ Lead Inspector Helen Macukiewicz Key Unannounced Inspection 27th June 2007 09:15 Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 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 Old Vicarage (The) DS0000020065.V340117.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 Adults 18-65. 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. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage (The) Address Market Place Riddings Alfreton Derbyshire DE55 4BQ (01773) 607479 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 Raymond Miles Mrs Pauline Ann Miles Jane Anne Selby Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2006 Brief Description of the Service: The Old Vicarage is a large old building in a pleasant area. It is well decorated and maintained. The home is within a short distance from local shops, churches and a park. The Registered Providers offer places for up to 10 people with learning disabilities, for male and female residents. The home has two flights of stairs, both going onto the 1st floor. This would make accommodating someone with mobility problems difficult, although there are some bedrooms and a bathroom and toilets downstairs. There is one double bedroom at the home. There is a lounge, separate dining area as well as a seating area in the kitchen. The home has two dogs and a cat. The range of fees per week varies between £392.00 and £540.00 and includes all expenses except for toiletries and newspapers. The last inspection report is made available by word of mouth; the Manager keeps a copy in the Home. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 6 hours over 1 day. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were referred to in the planning of this visit. Information provided by the Manager in her completed annual quality assurance assessment (AQAA) was also used to provide a focus for this Inspection. A decision was made with the manager not to send out preinspection questionnaires to service users, their views on the quality of this service were obtained from them directly, during this visit. During this Inspection discussion with every person who uses this service took place. There were no relatives or professionals such as Care Managers visiting that day. Time was spent in discussion with the Manager and staff. Two peoples care files were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. What the service does well: Comments from a visitor in a returned questionnaire that had been sent out by the Manager said the home is ‘just about perfect’. There is a sensitive and planned admission process, which would minimise disruption to the person being admitted and those already living in the Home. Care plans are designed to reflect the longer-term needs of the person and are person-centred. There is an excellent programme of social, educational and leisure activities, mainly external to the home to help people integrate within their community. One resident said to the Manager ‘we had a good time on holiday didn’t we’. Personal support to people living in the home is good, care is flexibly provided and people living in the home are happy with the level of choice and control over their daily lives. Comments from a visitor in a returned questionnaire that had been sent out by the Manager included ‘each resident is treated as an individual’. The building is very homely and well furnished and given the constraints of an older style building, provides an excellent standard of accommodation for people. There is a low staff turnover so service users benefit from having experienced staff who know them well. There are sufficient numbers of staff on duty at all Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 6 times and that staffing allows people living in the home to live fulfilling and varied lifestyles. One person living in the home said ‘I want to stop here for good’, another said ‘I like it here’. Comments about the staff specifically included ‘nice staff here – like everybody’ and ‘we get on with Jane (Manager) and all the staff’. What has improved since the last inspection? What they could do better: Further information in the Statement of Purpose and admission procedures would help anyone making a decision to move into the home clearer about the type of service provided, and ensure their admission was appropriate. Care plans had been reviewed although the frequency and depth of reviews varied. One care plan did not contain full information for staff to follow. Discontinued medication prescriptions need to be removed from the printed Medication Administration Record to avoid confusion. Although there was no evidence of this, the system for supporting people with their personal money does not offer full protection against the possibility of financial abuse. The presence of formal behaviour management plans would ensure better safeguards for people living in the home and staff. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 7 The Manager and Provider need to formalise their meetings and use them to produce an annual development plan for the home, which will help to focus areas of need and prioritise improvements in a planned and structured way, including quality assurance. There are a number of policies including a lone working policy that need developing. A risk assessment of the staff toilet area and water safety (Legionella) is needed. The use of door wedges to prop open first floor fire doors should be stopped. Please contact the provider for advice of actions taken in response to this inspection. 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. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the home and their representatives have some information they need to choose a home, which will meet their needs. EVIDENCE: The Manager stated that there have been no changes to the Statement of Purpose or Service Users Guide since the last Inspection. She confirmed that all people living in the home have been given a copy of the service user guide in the past, and that staff have talked them through the contents to ensure they understood what it said. The Manager felt it would be appropriate to go through the contents of the guide again, during a future residents meeting, as a reminder for people living in the home. This Inspection highlighted two areas of practice within the home, which were not included in the Statement of Purpose, and which would help anyone making a decision to move into the home clearer about the type of service provided: • The fact that the home would not accept emergency admissions due to possible adverse effects on the existing client group. DS0000020065.V340117.R01.S.doc Version 5.2 Page 10 Old Vicarage (The) • A statement that the home would not admit people who were known to be physically aggressive due to the fact that the homes’ behaviour policy states that staff would not use physical restraint. Discussion took place with the Manager about the admission process, and the steps she would take to ensure no person was admitted to the home inappropriately. She described a sensitive and planned process, which would minimise disruption to the person being admitted and those already living in the Home. A policy on admissions had been drawn up. On speaking to the Manager it appeared that this did not cover all elements of the admissions process that she described such as: • • No person would be admitted to the home without a full assessment of need either by Social Services, staff at the Home or both. Consultation with the existing group of residents and consideration of their needs would take place before a decision to admit a further person to the home is made. The Home has had no new admissions for over four years and as such the Manager said that she has not yet devised any paperwork that would be used for assessment purposes, but is aware of the need to do so. In the two care files seen on Inspection; there was an assessment of need completed by Care Management, which would be sufficient for staff to follow. The staff group are all of white British heritage; this meets with the needs of the current group of people living in the home. Discussion took place with the Manager about how the home might meet any cultural and diversity needs of people admitted in the future. The Manager said she makes the Inspection report available to relatives on request and keeps a copy in the Home. Comments from a visitor in a returned questionnaire that had been sent out by the Manager said the home is ‘just about perfect’. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals and/or their advocates are involved in decisions about their lives and as far as possible play an active role in planning the care and support they need. EVIDENCE: Three peoples care files were seen in more detail. Each contained a plan of care. All people living in the home are from white British heritage; their cultural and religious needs were documented in a section of the care plan set aside for this purpose. The care plans are designed to reflect the longer-term needs of the person and are person-centred, but also refer to changes in care needs that occur. The person living in the home signs them to support their involvement in their care. Both care plans accurately described the care provided by staff and the care needs of the person. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 12 Both care plans had been reviewed although the frequency and depth of reviews varied. One care plan did not contain full information for staff on how to observe for side effects of a variable dose medication the person was taking. The Manager is considering delegating some of the responsibility for filling in care plans to another member of staff to ensure information is updated and reviewed more often. The Manager confirmed that people living in the home have their care formally reviewed by Social Services Care Management annually. The Manager described ways in which she has advocated for people living in the home in regard to their health needs and personal aspirations. She has a working knowledge of the ‘Valuing people’ document and Mental Capacity Act. Most people have advocacy provided by relatives or staff in the home. The Home has used independent advocates in the past although for reasons outside the homes’ control, these were not available at the time of this Inspection. The Manager had already started preparations to acquire the services of another independent advocate. As far as possible the Manager enables people to manage their own finances and two people confirmed they could have money when they wanted. All had direct access to their money. Any person who participates in an activity that involves a degree of risk to them, had this documented in their plan of care along with a care plan to ensure safeguards are in place. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a varied and active lifestyle of their choice, which supports them to develop their social and life skills. EVIDENCE: All but one person living in the home attends a day centre or participates in activities away from the home. Three people attend an adult literacy group. Six people are members of the ‘Achievers Club’, and eight are social members attending swimming clubs weekly and local pubs. Everyone living in the home are members of Amber Gold (MENCAP) and regularly attend their social evenings and day trips. One person said he goes out to a day centre 4 days a week in the bus. The people living in the home were able to say what educational activities they undertake during the day. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 14 The Manager described well-established links with ‘Amber Gold’ (formerly MENCAP services) in Amber Valley where she sits on the Committee. She also had a good knowledge of local services and amenities. She intends to hold an open day in August, which she hopes will encourage members of the local community to visit the home. Community transport is used to assist people to attend community activities and the home also has a mini bus. The adult literacy group has changed days to Wednesdays, which has presented the Manager with difficulties providing transport due to other commitments on the mini bus. She is currently looking at funding for a taxi so people do not have their education disrupted. The Manager confirmed that she assists people to complete postal votes for local and national parliamentary elections. People living in the home are given their own post to open, with support from staff. The Home plans regular holidays both abroad and in the UK. Everyone went on a holiday in June 2007. One person said to the Manager ‘we had a good time on holiday didn’t we’. Minutes of ‘residents meetings’ document that people are involved in planning social events and activities. People living in the home said that they had been on holiday to Spain, go swimming, attend a literacy group and walk to local shops and pub. One person said that they had a boyfriend who they had met at a Social Club. The Manager was able to describe ways in which she has supported people to develop relationships with their peers. Staff were observed to routinely knock to request permission before entering peoples’ bedrooms. Staff interactions with people living in the home, observed during the day were very positive and respectful. People confirmed that whilst they are assisted to bathe, they are given privacy. One person was asked how they chose what to wear each day and replied ‘I do it myself’. Other people also confirmed that they choose their own clothes, with occasional support as needed from staff. Everyone helps to choose the weekly menus, taking it in turns. The breakfast menu was displayed in the kitchen and people were able to confirm that they had received what was written on the menu board and enjoyed it. People needing support to eat had this written in their care plans and were appropriately supervised during meal times. One person said ‘I like the food’ another said ‘its yum-yum’. Further comments from people living in the home included ‘there is enough food’, ‘we had a birthday party on my birthday and I had a birthday cake’, ‘we have take-aways – Chinese’ and ‘we had a Mexican night and barbecues’. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive meets their individual needs, and ensures their rights to dignity and respect are upheld. EVIDENCE: Whilst the routine of the home is largely dictated by planned activities, when these are not taking place people confirmed that they can stay in bed for longer in the mornings and they all said that they can go to bed at whatever time they want. One person living in the home said ‘ you don’t have to go out if you don’t want to’. Staff who work night shifts confirmed that they go to bed at the same time as the last resident and that this is flexible depending on the needs of the person. All people have a television in their bedroom and some said that they watch T.V. in their room at night. One person said ‘I play music in my room, lie down if I go to my room’. There are two telephones in the home that can be used by people living there; local calls can be made free of charge. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 16 Comments from a visitor in a returned questionnaire that had been sent out by the Manager included ‘each resident is treated as an individual’. Care plans showed links with specialist support services such as Hospital Consultants, physiotherapists and Mental Health Services. They also showed evidence that people are receiving the services of their G.P, optician and Dentist. One person said she has some’ new glasses coming on Monday, they are pink’. Annual meetings are held between the Manager and the dispensing chemist used by the home to ensure any issues/problems/questions with regard to medication are sorted out. There have been improvements in terms of the way staff handle medications since the last Inspection. The Manager confirmed that she has obtained an up to date medication reference book. She also confirmed that the Homes’ policy on administration of medicines had been updated. The Manager said she is currently looking into a course run by Derbyshire County Council, which is for staff who administer medications. Medication records were well maintained although discontinued medication prescriptions had not been removed from the printed Medication Administration Record. The Manager agreed to liaise with the dispensing chemist to get the items removed. The Manager confirmed there were no controlled drugs being used in the home. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are able to express their concerns and are protected from abuse, although gaps in training/policy and procedures means there is the possibility that peoples’ well being may not be fully safeguarded. EVIDENCE: There is a complaint procedure on display in the foyer, although ‘residents meetings’ are the most appropriate method for people who live at the home to raise their concerns/worries/opinions about the service they receive. The Manager said that she also encourages people to approach staff individually with their worries. She has looked at past minutes of residents meetings and has identified that some of the issues people have raised through that method should have been treated as formal concerns, and addressed accordingly. She has identified that the home needs to review the way concerns from residents are handled in light of this. Prior to the loss of the independent advocate in the home, she had been chairing some residents meetings to ensure a degree of impartiality. At the last meeting, the minutes recorded that one resident had said they had no problems and were happy living in the home. There have been no complaints about the service received by the Home, or to the Commission for Social Care Inspection since the last Inspection. People Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 18 who live in the home have signed the complaints procedure to say they have seen it, although the written procedure needs to be simplified to ensure it is appropriate to their level of understanding. One person said ‘ I would talk to staff or (named a senior member of staff) if there is a problem’. Another said ‘I am happy’, and another person said ‘everybody’s happy’. The Manager said that the ‘whistleblowing’ policy and procedures have recently been updated. The Manager said that staff are due for an update on Adult Protection/Safeguarding procedures. She has looked into sources of training and plans to book places on a course running in September, organised by Derbyshire County Council. The Registered Provider is the only member of staff who is yet to attend safeguarding training, but this would be appropriate as he does provide some day to day care for people living in the home. People who live in the home said they are happy with the Homes’ method of managing their day to day spending money. Although there was no evidence of this, the system does not offer full protection against the possibility of financial abuse. The Manager agrees to look into ways to provide greater safeguards. Care plans did include a risk assessment for people handling their own money, as a safeguard. There is a bullying policy in the policy file, and a policy covering aggression, which provides some guidelines for staff on how to handle aggressive behaviour. The policy does not specifically detail the rights of people who have been physically assaulted to make a police complaint (both staff and residents) and the support systems offered by the home to staff and residents following assault. However, the Manager confirmed that although these were not written down, both these requirements would be met in practice. Minutes of residents and staff meetings detail that staff have discussed issues of bullying and acceptable behaviour with the people living in the home and also between themselves as a staff group. In care plans, there are instructions for staff to follow should someone’s behaviour become unacceptable. However, these are not linked to an agreed behaviour management plans, the presence of which would ensure better safeguards for people living in the home and staff, and the fact that the home operates a no restraint policy. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is domestic in character and provides a comfortable and homely environment for the people living there. EVIDENCE: Since the last Inspection, the entrance halls have been redecorated, new flooring has been provided and the lounge has been redecorated. One bedroom and bathroom have also been redecorated. The Manager said they try to undertake maintenance work while people are out of the home or on holiday to minimise disruption. The Manager, in her pre-inspection information, said that there are plans to redecorate most of the bedrooms, mend or replace some garden furniture and remove some trees in the garden that are blocking out light. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 20 Some people living in the home gave a tour of their bedrooms and two confirmed they liked the colour of the walls and views from the windows, bedrooms were personalised with photographs and personal possessions. Most bedrooms are single occupancy but those people who share a room said they liked the person they shared with. Some people have keys to their bedrooms and/or front door keys. This is recorded in their care plans following a risk assessment. People had free movement around the home during the Inspection. People were encouraged to undertake household tasks such as ironing and bringing the washing off the line. The garden area is well maintained with attractive planting. There is garden furniture provided on a patio area. Comments from a visitor in a returned questionnaire that had been sent out by the Manager included ‘the Home is fresh, bright, happy and homely with a caring attitude’. All parts of the home were clean, tidy and well decorated. People were tidying their bedrooms on the morning of the visit. The building is very homely and well furnished and given the constraints of an older style building, provides an excellent standard of accommodation for people. Laundry facilities are adequate for the needs of the people living there. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a stable and knowledgeable staff group at the home who are deployed in a flexible way to ensure people living in the home have their needs met. EVIDENCE: In her pre-inspection information the Manager recorded that the staff group has not changed over the past four years, consequently all staff are experienced and knowledgeable about the people who live in the home. Returned questionnaires that had been sent to family and friends by the Manager, said that staff are well thought of and valued by them. The staffing rotas showed there are sufficient numbers of staff on duty at all times and that staffing allows people living in the home to live fulfilling and varied lifestyles. Gaps in the rota are covered from within the core staff team. Staff also accompany people on holidays as part of their normal duties. The Manager said that staff have received training relevant to their work in the home, areas covered include Ageing, Downs Syndrome, Diet and Nutrition. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 22 Mandatory training in areas such as moving and handling are also provided for staff. The Manager hopes to attend a computer course in the near future. Training records for all staff have been collated and put into a folder, this information is used to create an annual training plan for staff. The Manager said that there are no restrictions on the training budget although mandatory training in areas such as moving and handling take priority. Training records supported that there is a well-trained staff team, and that training is relevant to the care needs of people living in the home. The Manager hasn’t arranged for staff to attend infection control training as yet but plans to do so. She has acquired the services of an organisation through Skills for Care, who will identify the training needs of staff and source training for them. About 66 of all staff have qualifications to NVQ (National Vocational Qualification) level II. The recruitment files for staff were seen on the last Inspection, as there has been no further recruitment of staff in the home, these were not viewed again. The Manager confirmed that the requirement of the last Inspection, regarding recruitment, has been undertaken. The Manager has increased the regularity of staff supervision but is still not able to achieve the recommended frequency of six times a year. She does work closely with staff on a day to day basis to observe practice and discuss any issues the member of staff might have. The minutes of staff meetings supported that there is discussion about the needs of each person living in the home, as well as training and general planning issues. The Manager intends to delegate some supervision of staff to another senior member of the staff team in an attempt to increase the frequency of the formal supervision of staff. The staff team felt supported, and able to discuss any concerns they have with the Manager. They had an excellent knowledge of the needs of the people in their care. People living in the home knew the names of all staff members and openly displayed affection for them. One person said ‘I want to stop here for good’, another said ‘I like it here’. Comments about the staff specifically included ‘nice staff here – like everybody’ and ‘we get on with Jane (Manager) and all the staff’. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from a well managed service, which is based on openness and respect. EVIDENCE: The Manager is very experienced and has a registered managers award. Training records supported that she attends training courses relevant to her role. The Owner and Manager meet regularly to discuss the development of the home. The Manager recognises the need to formalise these meetings and to use them to produce an annual development plan for the home, which will help Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 24 her to focus areas of need and prioritise improvements in a planned and structured way. The Manager has made a start towards developing internal quality assurance systems, she has sent out some satisfaction questionnaires. These do not include questionnaires for stakeholders within the community as yet. The Managers self-assessment questionnaire, which she completed prior to this Inspection, identified a number of policies including a lone working policy, that needed developing and she is aware of the need to undertake this work. The Registered Provider had been undertaking formal monitoring visits to the Home but this has not been continued. This is due to the fact that they are in day to day contact with the home and work alongside staff most days. This level of input is not currently recorded on the staffing rotas. A lock has been provided for a cupboard, which is used to store chemical cleaning agents to make the home safer for people living there. (Evidence from AQAA) Staff meeting minutes recorded that staff have been informed about this new arrangement. Various risk assessments were seen covering areas such a safe surface temperatures of radiators and falls from a height. The Manager confirmed that all bathroom and toilet areas have locks that can be accessed from the outside in case of emergency. The staff room toilet does not. This area can be accessed by people living in the home and will therefore need a risk assessment. Service records that were seen were up to date. Some Legionella prevention work is recorded although the Home has not had a formal Legionella risk assessment and water maintenance program drawn up. The Manager said it would be no problem for her to get this work done. All areas of the home appeared safe with the exception of the use of door wedges to prop open first floor fire doors. People were supervised when using the iron, for their safety. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 x 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 3 X 2 2 X 2 x Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(1) and (2)(b) Requirement Service users care plans must be reviewed in depth every six months or as care needs change. Care plans must provide clear instructions for staff on how to observe for side effects of medication (anticoagulants). To ensure the well being of service users is protected. Timescale for action 31/08/07 2. YA20 3. YA23 4. YA42 Records relating to discontinued medications must be removed from Medication Administration Records to ensure records are clear and ensure the safety of service users. 13(6) The financial procedures for handling service users money must be reviewed to allow for detection of possible financial abuse. 13(4)(a)(c) Risk assessment of Legionella safety and the staff room toilet door lock must occur. Fire doors must not be wedged open. To ensure the safety of service users. 13(2) 31/08/07 31/08/07 31/07/07 Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 27 (timescale for Legionella risk assessment is 31/08/07) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. YA1 Refer to Standard Good Practice Recommendations The Statement of Purpose should include the following information so that people have a greater understanding about what type of care the service provides:• • The fact that the home would not accept emergency admissions due to possible adverse effects on the existing client group. A statement that the home would not admit people who were known to be physically aggressive due to the fact that the homes’ behaviour policy states that staff would not use physical restraint. 2. YA3 The admission policy should include the following information to ensure no person is admitted inappropriately to the home:• No person would be admitted to the home without a full assessment of need either by Social Services, staff at the Home or both. Consultation with the existing group of residents and consideration of their needs would take place before a decision to admit a further person to the home is made. • 3. 4. YA22 YA23 The complaint procedure for service users care plan should be simplified to make it more understandable. The Registered provider should attend Safeguarding training to ensure service users are protected. The physical assault policy should cover:- Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 28 • • The rights of people who have been physically assaulted to make a police complaint (both staff and residents). The support systems offered by the home to staff and residents following assault. 5. YA36 Formal behaviour management plans, should be drawn up with agreement from the service user/advocate/professionals involved in their care, to ensure better safeguards for people living in the home and staff. These should be linked to a behaviour management policy for the Home in general. Staff should have regular recorded supervision meetings at least 6 times a year. (This was also a recommendation of the Inspection Report dated 4 July 2006). Feedback should be formally sought on the home from visiting professionals The annual development plan should be formalised into a written document (These were also recommendations of the Inspection Report dated 4 July 2006). The involvement on a day to day basis of the Registered Provider should be included on the staffing rota. 6. YA39 7. YA40 All missing policies and procedures identified through the Annual Quality Assurance Assessment should be devised, including a lone working policy for staff. Old Vicarage (The) DS0000020065.V340117.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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