Inspection on 09/10/07 for The Old Vicarage

This inspection was carried out on 9th October 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 04/11/08

The Old Vicarage 27/06/06

The Old Vicarage 24/01/06

The Old Vicarage 01/12/04

The Old Vicarage 14/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Vicarage 15 Naze Lane Freckleton Lancashire PR4 1RH Lead Inspector Ms Susan Dale Key Unannounced Inspection 11:30 9th October 2007 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 DS0000009853.V346469.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 DS0000009853.V346469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address 15 Naze Lane Freckleton Lancashire PR4 1RH 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) 01772 635779 01772 633269 old.vicarage@arc-homes.co.uk Aegis Residential Care Homes Ltd Lorraine Anne Mynott Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (3) of places The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users. Within this number up to 35 service users can be in the category of Older People (OP) and a maximum of three service users in the category of Physical Disability (PD). 27th June 2006 Date of last inspection Brief Description of the Service: The Old Vicarage was originally an old manor house standing in its own grounds, and is situated in the village of Freckleton close to local amenities. The home provides personal care for service users of both sexes but does not provide nursing care; any nursing advice or support is provided by district nursing staff. Advice is also sought from other health care professionals including General Practitioners, Chiropodists and Physiotherapists. All meals are provided and any special requirements catered for. The home is not purpose built however, a large extension has been added to the original building and this has been designed specifically for the requirements of older people or persons with a physical disability; the new extension includes 7 bedrooms with en-suite facilities and 2 lounges. A large patio area with seating has also been incorporated and the gardens landscaped. Service users are able to access all parts of the building and grounds via a lift and various ramps. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was unannounced and focused on key standards. The inspector was able to speak to service users and staff and examine various records. Surveys were provided to service users, relatives/friends and health professionals prior to the inspection. 10 surveys were returned from service users, 3 from relatives and 1 from a general practitioner (GP), the comments were taken into account as part of the inspection. A tour of the premises took place. What the service does well: What has improved since the last inspection? A new pro-forma for recording the initial assessment is now being used. The format enables the assessor to make an initial judgement on the mental capacity of the person and whether the home will be suitable. A new form has been devised that details very clearly the handling plan for each service user; the details are kept within the bedrooms. There is also now The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 6 a pro-forma in use that is completed by staff twice a day on individual events, care or health requirements and the details are then transferred to the main files. Photographs are provided to relatives of the service users when they are on trips out and an album is kept in the entrance hall of the home featuring photographs of service users enjoying activities. Permission is sought from service users before any photographs are taken and displayed. Each month a newsletter is devised and given to each service user. The newsletter is available to all visitors within the home. The details include the ‘life story’ of one of the service users. Jugs of water and juice are now freely available within the various lounges. The dining room has been refurbished and provides a very pleasant environment with new chairs that slide easily under the tables and they are attractively laid out with wine glasses and napkins. A serving trolley has been purchased. One of the chefs is attending a course put on by Fylde Borough Council and Environmental Health called ‘Taste for Life’ and Hazard Analysis Critical Control Point (HACCP) respectively. The home will be audited on its performance by Fylde Borough Council as part of an Excellence if Food Award. The manager has recently purchased a Gazebo to provide cover from any inclement weather. The home now has locks on all individual bedrooms, which ensure privacy but can be opened from the inside by service users or by staff who hold keys from the outside. Liaison has taken place with a Fire Safety Officer and action was taken to ensure that the fire doors were safe following an incident when a service user went out through a fire door. What they could do better: A recommendation was made that staff need to expand on the details recorded where there is an aim or personal objective. The care plan needs to state how the aims are to be achieved instead of making a general statement. There is also a need to expand on the background and history of the individual service users where possible. Any allegation of Abuse must be referred to Social Services and the Commission in order to ensure that the Health Safety and Welfare of the vulnerable persons living in the home are protected. As well as the Abuse training already provided to staff, all staff should be made aware of the reporting procedures in the event of any Abuse in order to protect vulnerable persons living in the home. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 7 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. The Old Vicarage DS0000009853.V346469.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 DS0000009853.V346469.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): 3&6 Quality in this outcome group was good. Information is available about the home and services provided. Service users are assessed in way that ensures the home is suitable for them and can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Any person who is considering whether to live at the home is able to have a trial visit and stay for a maximum of 4 weeks to sample the services provided. A full assessment is also carried out to ensure that their needs can be met by the home. A new pro-forma for recording the initial assessment is now being used. The format enables the assessor to make an initial judgement on the mental capacity of the person and therefore whether the facilities provided by the home will be suitable. As part of the initial assessment process any risk connected with the environment are looked at and assessed including a ‘room’ risk assessment. A checklist is completed to ensure that the room is ready for the new occupant. Service users and a relative were spoken to about their experience of being newly admitted to the home and they all indicated that it had been a positive experience. The home does not provide intermediate care. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 10 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 group was good. A plan of care is devised that meets all physical, emotional and health requirements and is delivered by staff in a sensitive manner that respects service users’ privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The initial assessment leads to a plan of care that is recorded on a Standex System and is kept under review. As at the last inspection, the pro-forma used for recording care plans etc., is comprehensive but very prescriptive and does not allow much room in the boxes for any detail. The small print is also not user friendly for a person with sight difficulties. The care plan includes individual wishes and staff are aware of the need to promote equality and diversity. With regard to personal care, wishes are recognised as to whether a male or female carer is preferred and religious or cultural requirements are recorded and implemented. A recommendation was made that staff need to expand on the details recorded where there is an aim or personal objective. The care plan needs to state how the aims are to be achieved instead of making a general statement. There is also a need to expand on the background and history of the individual service users, where this is possible, to present a more rounded picture and help in The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 11 the formulation of a suitable care plan. There was evidence of a monthly review and a signature had been obtained from the service user at the initial stage and for each review. The care plans seen covered all areas and a separate record is kept for any visits by health professionals. Management and staff are liaising with General Practitioners (GP’s) and District Nurses over the care of service users and a GP confirmed that they have not had any concerns with regard to the healthcare of the service users. There have been a number of falls and serious incidents reported to the Commission for Social Care Inspection (CSCI) and these were discussed with the registered manager. The manager has conducted risk assessments following any incident and kept a record of the falls and works closely with a Falls Co-ordinator from the local Primary Care Trust. A record had been kept of baths and showers, weight and continence; staff had received training in catheter care. A new form has been devised that details very clearly the handling plan for each service user; the details are kept within the bedrooms. A relative has commented that she was pleased when following concerns raised, the manager took action over the need to check whether a hearing aid was working and placed a checklist within the room. There is also now a proforma in use that is completed by staff twice a day on individual events, care or health requirements and the details are then transferred to the main files. The manager has instigated this to ensure that more details are recorded on a daily basis. Another relative stated: “They seem to try hard to meet the needs of the all their residents but, it is difficult when they are not always able to express what those needs are.” Policies and procedures are in place that ensures the storage and provision of medicine meet the standard required. Medication is stored in an appropriate purpose built trolley that can be secured to the wall. A record is kept of the medication provided and oversight to ensure the details are correctly recorded is provided by the manager on a regular basis. Controlled drugs are suitably stored in a separate area and a record is maintained. Currently nine staff are trained to provide medication. From observation, service users and relatives spoken with and comments from surveys, staff treat service users with respect and their dignity and privacy is respected. There has been a recent incident whereby a service user was not treated with dignity and a staff member reported the incident to management; disciplinary action was taken immediately. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 12 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 group was excellent. The home provides activities that meet the expectations and capabilities of the service users and visitors to the home are made to feel welcome at all times. Service users are provided with nourishing meals that offer choice at regular intervals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the initial assessment service users are asked about hobbies and interests and a comprehensive daily programme of activities is now in place with a dedicated activities co-ordinator. Activities include T’ai Chi, exercise, karaoke, biscuit making, crafts, barbecues and regular outings. Trips have been made to the Lake District, Penny Farm and tea dances. During the site visit a game of dominoes and carpet bowls was taking place and relatives were joining in and all seemed to be enjoying the events taking place. The activities coordinator was spoken with and she confirmed that her role was expanding and that there were activities available according to ability. Some service users are not particularly active but, enjoy gentler stimulation such as hand massage or taken for a walk locally to the pub or church. Photographs are provided to relatives of the service users when they are on trips out and an album is kept in the entrance hall of the home featuring photographs of service users enjoying activities. Permission is sought from service users before any photographs are taken and displayed. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 13 Each month a newsletter is devised and given to each service user. The newsletter is available to all visitors within the home. The details include the ‘life story’ of one of the service users and all concerned has seen this as a very positive contribution. A relative spoken with commented that they were always made to feel welcome and had nothing but praise for the staff over their care of the service users. Relatives made the following comments: “There are regular trips out which I am very pleased about.” and “Provides a reasonably stimulating environment.” In a staff survey there was a comment about what the home does well: “Provides excellent days out and activities for the residents.” A relative made the following comment: “More fruit and vegetables and less stodge example, thick bread, cakes with no nutritional value.” The manager stated that fresh fruit is always available and kept for anyone to pick up at the entrance to the dining room. Toast is made with thick bread but otherwise the bread has medium slices. Service users confirmed that they were very happy with the meals provided and that there is a plenty of choice. Jugs of water and juice were seen to be freely available within the various lounges. At the initial assessment a record is kept of service users wishes with regard to food and any requirements are recorded on the care plan. Some of the service users require their food to be liquidised and some require extra nutrition to help them gain weight. A nutritionist has been contacted for advice where necessary and a record is maintained of weight. The dining room has been refurbished and provides a very pleasant environment with new chairs that slide easily under the tables and they are very attractively laid out with wine glasses and napkins. There are two chefs and one spoken with is attending courses put on by Fylde Borough Council and Environmental Health called ‘Taste for Life’ and Hazard Analysis Critical Control Point (HACCP) respectively. The home will be audited on its performance by Fylde Borough Council as part of an Excellence if Food Award. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 14 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 group was adequate. Procedures with regard to reporting Abuse need to be strengthened to ensure the protection of vulnerable service users. Complaints/concerns are recognised and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints/concerns are recognised and acted upon. There has been one complaint made to the home and the details recorded showed that a thorough investigation had taken place and changes made to ensure effective changes were made where necessary. The manager also records any minor concerns and keeps a record of compliments. Staff are expected to conform to the Code of Conduct issued by the General Social Care Council and their expected level of performance is always discussed at induction. There have been a number allegations/incidents with regard to the staff. The correct procedures for reporting any allegations of abuse need to be strengthened to ensure that they are reported according to local and national agreements on the Protection of Vulnerable Adults (POVA). There was evidence that all staff have received training on POVA. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 15 Immediate action has been taken on all allegations but there is a need to ensure that joint decisions are made with Local Authorities, Police and the Commission for Social Care Inspection (CSCI) in accordance with the POVA regulations and to ensure that a thorough investigation is carried out. Some decisions appear to have been made by senior management when the registered manager was on holiday without notifying or discussing the events with the appropriate sources as outlined above. A requirement was issued that in the future, any allegation of Abuse must be referred to Social Services in the first place and the Commission in order to ensure that the Health Safety and Welfare of the vulnerable persons living in the home are protected. As well as the Abuse training already provided to staff, all staff should be made aware of the above reporting procedures in the event of any allegation of abuse in order to protect the vulnerable persons living in the home. There was evidence that new staff are checked on the POVA register prior to commencement at the home. Policies and procedures are in place with regard to the service users’ money and financial affairs with up to date records seen to be kept. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome group was excellent. The home provides luxurious safe accommodation for both service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides luxurious accommodation since it was extended and refurbished with attractive communal rooms as well as individual bedrooms. The corridors are wide and spacious and make it easy for wheelchair users. Almost all the individual bedrooms have now been refurbished to bring them up to the same standard as the new extension. Some of the rooms have patio doors that open onto the gardens. The large communal lounge has a kitchen area for use by staff and those service users able to make a drink etc. New furniture is within the dining room and there is now a serving trolley. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 17 All service users can access a new patio area and the gardens have been landscaped. The manager has recently purchased a Gazebo to provide cover from any inclement weather. The home now has locks on all individual bedrooms, which ensure privacy but can be opened from the inside by service users or by staff who hold keys from the outside. There was an incident whereby a service user accessed a fire door and the manager took immediate advice from a fire officer who has advised that child lock could be fitted to the two fire doors with bars to ensure there no further incidents. There is now a sluice and a dedicated medication room. Generally the home was clean, warm and there were no unpleasant smells. A service user stated: “I find it nice and clean.” The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 18 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 group was good. The staffing levels are sufficient to meet the needs of the current service users. Staff receive training that assists them to care for vulnerable service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were sufficient staff on duty at the time of the site visit. Currently there are some staff vacancies and the manager is hoping to increase the staffing levels to ensure that there is always a ‘spare’ member of staff for any emergencies. A comment was received from a relative with regard to how the home could improve: “Staff to be on hand all the time in the lounge with the residents.” The manager stated that the instructions were for a member of staff to be in the main lounge at all times. From time to time for this may not have been possible as staff had to care for service users in other areas of the home. There are now 19 care staff and 6 ancillary staff; 6 staff have an NVQ qualification in Care and a further 9 staff are in the process of obtaining an NVQ qualification. The registered manager is qualified to assess staff for moving and handling. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 19 A mandatory training programme that all staff have to complete as well as NVQ includes: First Aid, Food Hygiene, Fire Safety, Infection Control, Health & Safety, Moving & Handling, Dementia Care, Abuse Awareness, Customer Care, and Medication Training. Staff made very positive comments about the amount of training they receive and that they receive appraisals and supervision. Comments included: “Induction covered all areas from manual handling to incontinence and care plans.” “Keeps us up to date with training.” Staff spoken with during the site visit also said that they were encouraged to attend training and felt very well supported by the manager. A key worker staff system of working is in operation. Staff had been recruited appropriately with suitable checks undertaken with the Criminal Records Bureau and the Protection of Vulnerable Adults Register; two written references had been obtained. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 20 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 group was good. The service users and staff are led, protected and cared for by a manager who has lengthy experience in care and the management of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current manager has undertaken various courses to assist her in the management of the home and has lengthy experience in the provision of care and management. There is still a need for the manager to obtain an appropriate management qualification and provide the evidence to the Commission. The manager has made numerous improvements to the home and has strengthened the existing policies and procedures. All staff are taught to record any care provided in detail and the importance of maintaining all records such as weight, baths and activities. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 21 Staff confirmed that basic training in all aspects of health and safety is provided and was evidenced through induction documentation. Risk assessments are carried out on all safe working practices. All staff praised the support they received from the manager and that she was very approachable. Staff meetings are held every 6 weeks with a separate meeting for senior staff and one to one supervisory meetings are held with all staff. Staff comments included: “The home looks after the majority of needs of all the residents, most of the requests are dealt with quickly and efficiently and any complaints or concerns are also dealt with quickly.” “The Old Vicarage always seems to be looking for ways to improve the services so it makes everything better.” “The service has high standards and a good team of staff who are dedicated to the needs of the service user.” Regular meetings are also held with service users and their relatives are invited. Annual surveys are sent out to families and the results are kept in the front entrance of the home. The results are analysed and the manager draws up an action plan. The home has the Investors in People Award. Both service users and their relatives confirmed that they would know whom to approach in the event of any concerns and confirmed that immediate action had been taken over any concerns. Regular Audits are carried out within the home including a Quality Assurance Audit and a Medication Audit. The area manager undertakes regular visits to the home to ensure that standards are being met and the information is fed back to the Commission for Social Care Inspection. The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 22 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 X 3 X 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 23 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 OP18 Regulation 12 Requirement Any allegation of Abuse must be referred to Social Services and the Commission in order to conduct an investigation to protect the welfare of the vulnerable persons living in the home. Timescale for action 31/10/07 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 2 Refer to Standard OP7 Good Practice Recommendations The care plan should include details as to how any individual aims/objectives are to be achieved and the details should be reviewed once a month. As well as the Abuse training already provided to staff, all staff should be made aware of the reporting procedures in the event of any Abuse in order to protect vulnerable persons living in the home. OP18 The Old Vicarage DS0000009853.V346469.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 DS0000009853.V346469.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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