CARE HOMES FOR OLDER PEOPLE
The Old Vicarage (Askam) Ireleth Road Askam In Furness Cumbria LA16 7JD Lead Inspector
Marian Whittam Unannounced Inspection 24th October 2007 10:00 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 (Askam) DS0000048089.V344904.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 (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Old Vicarage (Askam) Address Ireleth Road Askam In Furness Cumbria LA16 7JD 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) 01229 465189 tov.askam@btopenworld.com Vicarage Care Ltd Mr Carl Terence Raine Care Home 30 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability (1), Mental disorder, excluding of places learning disability or dementia (3), Old age, not falling within any other category (26) The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 30 service users to include: up to 26 service users in the category of OP (Old age, not falling within any other category) up to 12 service users in the category of (DE(E) (Dementia over 65 years of age) up to 3 service users in the category of ME (Mental disorder, excluding learning disability or dementia) 1 service user in the category of LD (Learning disability) 17th July 2006 Date of last inspection Brief Description of the Service: The Old Vicarage, Ireleth, is a residential care home providing care for people with a range of care needs. The home is in a residential area on the edge of the village of Ireleth. It is within walking distance of the local shops and a public house and the small town of Askam with more shops and a post office. The home is in a large detached house and is on two floors with a single storey extension and a conservatory to one side of the house. There is a stair lift to provide access to the first floor for less mobile residents. There is a secure garden area at the side of the home with seating for service users. The grounds are well maintained, have seating for residents and are wheelchair accessible. There is also a sheltered inner courtyard patio area with seating close to resident’s rooms. Information is available to prospective residents in the Statement of purpose and service users guide; this is available in the home. The fees charged by the home range from £373.00 to £434.00 per week as at the date of the inspection. An additional charge is made for personal toiletries and cigarettes, newspapers, magazines, and any personal travel expenses. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit to The Old Vicarage that forms part of the key inspection took place over five and a half hours. A full tour of the premises was also made. Information about this service was gathered in a number of ways prior to this visit: • Annual Quality Assurance Assessment completed by the registered manager. • Survey questionnaires returned by the residents, their relatives and healthcare professionals. • The service history. • Interviews with residents, management and staff on the day of the visit. What the service does well: What has improved since the last inspection?
The care plans have improved since the last inspection as they now present a clearer and more easily followed plan of care that is easier to monitor for changes. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 6 A greater effort is clearly now being made to find out more about people’s social and general backgrounds and life stories. This helps to identify things that might interest people and their cultural and religious needs. The improvements found at the last inspection in medication handling have been maintained to promote greater safety for residents. General redecoration has been taking place maintaining and improving the environment for people. Some bedrooms have been fitted with new flooring and windows at the front of the home have been replaced. The owners have also begun work on improving the garden and providing new outdoor furniture. What they could do better:
The Statement of Purpose should be improved to include the full range of facilities, services and support the service gives to its residents with dementia and mental health problems. Given that the home’s statement of purpose says they do provide services for people with dementia and mental health problems it should contain more detail on what it does for them. Not all staff have had up to date dementia care training to raise and develop their awareness and understanding of the range of conditions people living there have. This should be done to ensure good practices are followed. Training records are not systematic and up to date overall. The registered manager must make sure that there is a consistent and coordinated staff training and development programme in operation to make sure care staff receive all the training they need to fulfil their roles. The registered manager should make sure that formal staff supervision takes place allowing staff to address current practice matters and identify any career development needs. All care staff working in the home must be fully trained in identifying abuse and ‘Safeguarding Adults’ procedures. This training, reflecting current good practice, must be given to all staff so all are fully trained in recognising abuse, safeguarding adults and that they know when they need to refer to other agencies for investigation. The manager should also carry out a full review of the service’s own adult protection procedures as some aspects of their procedures are not in line with local multi agency guidance to safeguard vulnerable adults. The registered manager should also get a copy of the Department of Health guidance” No Secrets” to inform the home’s current practices. Care plans should be developed to be more person-centred and include information to reflect individual perspectives, goals and support needs. They should also have clear information about specific actions needed for people with challenging behaviours. Medication handling is generally good but for safer practice, staff should make sure that handwritten changes to medication administration records are checked by another staff member. This helps reduce the risk of error if someone else verifies and signs when they check. The safe practice of using protocols for the administration of “when required” medicines should be
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 7 introduced for all such medication so people receive these medicines only when needed. . 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 (Askam) DS0000048089.V344904.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 (Askam) DS0000048089.V344904.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): NMS 1, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some information about the home is available and there is an assessment procedure for people coming to live there so their needs can be identified although lack of specialised dementia training may affect how well those needs are met. EVIDENCE: Admissions are not made to this service unless an assessment of individual needs has been completed. A newer resident told us that the manager came to see them before they came in and asked them about themselves and told them about the home. Care plans indicate that where needed external specialised services continue to be involved with people’s care when they come to live in the home. If the Local Authority has undertaken an assessment, the home asks for a copy of the documentation for information. The home has an
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 10 introductory trial period followed by a review to make sure the home suits the person. Staff observed showed patience and sensitivity towards residents with dementia and challenging behaviour. However not all staff have had up to date dementia care training based on current good practice to raise their awareness and understanding of the range of conditions people living there may have. They need to have such training so people coming to live there can have confidence that that all care staff will have the skills they need to deliver the dementia care the service says it provides in its Statement of Purpose. The combined statement of purpose and service user guide should be updated, to provide up to date information to prospective users of the service. This should include the full range of services and support it offers to provide for people with dementia. The documents are available in the home in a standard written format that is given to prospective residents in an information pack. People living in the home told us they knew about the home before they came in and had information about it. Prospective residents and/or their families are invited and encouraged to visit, to speak with the manager and staff and other people living in the home. The service does not provide intermediate care. The Old Vicarage (Askam) DS0000048089.V344904.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): NMS 7, 8, 9 and 10 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 is based on their identified needs. People’s privacy and dignity are respected. EVIDENCE: All people living in the home have an individual care plan, based on initial assessments and risk assessments, setting out assessed health, social and personal care needs and these are being reviewed and updated by senior staff. These plans have improved since the last inspection to provide a clearer and more easily followed plan that monitors the individual’s assessed needs. Staff spoken with are aware of residents care needs and their individual preferences. During the visit we looked at a sample of four plans and found them to give sufficient information to staff although this was very much from the carer’s perspective on providing care rather than the resident’s perspective. For good practice a more individualised approach to a person’s care should be
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 12 considered to include the person’s own perspective, where possible, on how they want to be supported, cared for and their independence promoted There was evidence in the care plans and daily notes of health care treatment and intervention and an outline of the care required to meet the residents’ needs. A survey response from a GP attending the home was that “appropriate medical care is always organised”. We found some gaps in information and assessments recorded for people, for example there were no details in the care plan for the use of ‘as required’ medication for one person and no administration protocol in the medication records to guide its use. Also one person who exhibited quite challenging behaviour did not have an action plan in place to give detailed information on that behaviour and the actions staff should follow to support them and safe guard other residents. The service has systems in place to monitor the receipt and return of medicines. This allowed checks to be done and this showed that residents received safe and effective treatment in the prescribed dose. Storage was good overall so that people living there received good quality medicines. To promote safer medication practice and to reduce the risk of medications being given inappropriately administration protocols should be in place for use of ‘as required’ medicines to a person. Clear protocols for individual medicines would make it clear to all staff when and why an ‘as required’ medicine needs to be given and its effects and when to get further assistance. Administration records had been signed when medicines were given to residents. Generally medication administration records are printed by the pharmacy but changes are handwritten by staff. Where changes need to be handwritten then for good practice to reduce the risk of error staff should have them checked and verified by another member of staff. Observing staff going about their duties and talking with residents during the day we could see that they were approachable, polite and generally respected individual’s wishes and privacy. This was very positive and it was evident that the staff knew the residents very well indeed. One person told us they felt they had “made the right choice to come here” and they could not think of anything else they wanted staff to do to make it better for them. The Old Vicarage (Askam) DS0000048089.V344904.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): NMS 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their lifestyle and are supported to maintain their interests and independence. EVIDENCE: The routines in this home are flexible to meet the needs of those living there. For example one person had been out clothes shopping in the morning with a member of staff and their lunch was kept for them. Useful work has been done on getting ‘pen pictures’ of people and better information of people’s social and recreational needs. There was good background information to help identify social and cultural needs and people’s personal aspirations. It was evident from observations during the day that staff saw spending time with residents and supporting them with their interests as a normal part of daily life in the home. A senior carer organises the daily activities on offer and these are displayed on the notice board. These daily activities within the home are organised around
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 14 what people want to do on the day, like bingo or music, as people want. One person told us that these were for the people who could not go out. People told us told us about how they are supported to access and take part in social and recreational opportunities and people found some things more important than others. For example people told us about their shopping trips, trips out for drinks or meals and more than one about how much they had enjoyed a recent group holiday to Blackpool. For another person it was important to be supported to travel to see relatives for visits and holidays. People also said they did not have to take part in anything if they did not want to. People also told us that they could come and go as they pleased as long as they let staff know and see whom they wanted to. Several people went out for walks in the village and grounds during the visit. People told us that the food was good and that they were asked everyday by staff what they wanted from the choices on offer. Staff showed us the 4 weekly menu and the choices available each day. A record was kept of what people had chosen to eat and special diets. One person said that special requests for food are catered for. People are supported to handle their finances where possible but generally people are supported by their families, legal representatives and social services with financial matters. There is also information available and displayed on using advocacy services. The Old Vicarage (Askam) DS0000048089.V344904.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): NMS 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and system in place and available to residents and visitors so they can be sure complaints will be listened to, but inconsistent staff training around Safeguarding Adults may put people at risk. EVIDENCE: There are suitable procedures in place for dealing with complaints with records kept of complaints, correspondence and actions taken. The complaints policy and procedure is part of the guide for the people using this service and there was also a copy on display. This is not available in any alternate formats. The manager said that there had been no complaints for some time and The Commission for Social Care Inspection (CSCI) have not received any. People we spoke to told us they knew who to complain to, one person said “I would go to the boys if anything was wrong or I wanted something”, referring to the registered manager and his brothers who run the home. Another said they had never needed to make a complaint but would speak to the supervisor first. Survey responses support that people felt they would be listened to if they were not happy with something, although a small number were not sure how to make a complaint. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 16 The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA) and referral to POVA but a copy of the Local Authority’s procedure was not available. The manager should carry out a review of the service’s own adult protection procedures as some aspects of their procedures are not in line with local multi agency guidance. This might lead to confusion amongst staff if they needed to make a referral or inappropriate handling of an incident that might leave a person at risk. To promote good practice and inform the service’s own procedures the manager should also get a copy of the Department of Health guidance” No Secrets”. The manager has already completed a training course, run by social services, on protecting vulnerable adults so this training can be given to staff. Although this was also the case at the last inspection the manager has yet to organise training and pass this information on to staff through structured training. This is despite assurance at the last inspection that it was being implemented. This training reflecting current good practice must be given to all staff so all are fully trained in recognising abuse, safeguarding adults and that they know when they need to refer to other agencies. This is very important especially as care plans for some people living in the home show they have challenging and unpredictable behaviour and staff must know how to identify abuse and react effectively to safeguard people. The lack of clear and organised training records and individual staff training profiles makes it difficult to be sure what training has been given to all staff in the past on recognising abuse and how to protect vulnerable adults. The Old Vicarage (Askam) DS0000048089.V344904.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): NMS 19 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a comfortable and homely living environment. The premises are reasonably well maintained and kept to a good standard of cleanliness. EVIDENCE: Some internal redecoration has been completed since the last inspection in bedrooms, communal areas and ground floor corridors. Some bedrooms have been fitted with new flooring and windows at the front of the home have been replaced. The owners have also begun work on improving the garden and providing new outdoor furniture. The service does have a development plan for the next year and it was clear from a tour of the premises that routine redecoration and maintenance is being done.
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 18 There are two large lounges with a large conservatory and dining areas on the ground floor and a smaller lounge/diners on the first floor. There are also sitting areas in the hallways on the ground floor that is occasionally used by the residents. The home does therefore, provide a physical environment that is, on the whole, appropriate in size and facilities to meet the specific needs of the people who live there. There is also an internal courtyard entrance that several people were seen to use and sit in. There are two bedrooms that are shared but this is only with the agreement of the people using this service. Screens are provided for privacy and dignity when delivering personal care. Residents are encouraged to personalise their rooms and have done so with pictures, ornaments and photographs. The home is clean and tidy and there is a range of equipment and adaptations in the home to help residents make the most of their independence and to get about the home. Over half the bedrooms have en suite facilities but there are sufficient toilets, assisted baths and showers for people to use. The laundry is small but well organised, clean and tidy. Staff were seen following appropriate infection control procedures, using gloves and appropriate protective clothing. COSHH substances were locked away. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 19 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): NMS 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service uses appropriate recruitment procedures to protect residents but inconsistent staff training and development planning and recording means people living there cannot always be sure staff have the skills to meet their needs. EVIDENCE: During this visit we looked at samples of staff recruitment records and found them to be in order although rather disorganised. All prospective staff are requested to complete an application form, supply referees and attend for interview. Special checks such as Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) first are undertaken prior new staff to starting work. This helps to ensure the safety and protection of those living in the home. Staff rotas were checked and found to be appropriate to the number and needs of people living there. We saw that the staff interacted well with the residents and although there was plenty of light-hearted conversation this was carried out in a polite and friendly manner. People living in the home made positive comments to us about staff and told us they were “helpful” and another that “they are always there to help me get up and things”.
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 20 We could not find evidence of an annually planned and systematic staff training and development programme in current operation. This is needed to make sure that the care staff always get the right training they need to fulfil the home’s stated aims and be able to meet the changing needs of people living there, such as dementia care, adult protection and challenging behaviour. The manager is aware that there are some gaps in the in the training programme and individual staff records and plans to deal with these. The improvements made in training provision and planning seen at the last inspection have not been carried through. At the last inspection the manager had started to put training plans, training records and training profiles in order but this work has not been maintained or further developed to a consistent level. Consequently it was difficult to assess what training and development each member of staff had done, asked for or needed to do. Records of moving and handling training having been done and fire training had been kept separately and these were current. Staff did tell us that they had access to NVQ training and several had completed this and others were enrolled on it. The home needs to make sure this training continues to meet the 50 target. Supervisors were able to confirm that they had medication training. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 21 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): NMS 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use this service live in a home that is maintained safely, run by a qualified manager and protects their financial interests. EVIDENCE: The registered manager has the qualifications and experience to run the home. There are clear lines of accountability within the management roles and between care staff. There are occasional residents meeting and the home has used a system of annual satisfaction surveys to get feedback from people. There are staff meetings and all such meetings should have minutes taken and distributed.
The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 22 The manager has carried out an audit to update some policies and procedures and occasionally on medication practices and this quality monitoring should continue to be developed. The management had begun to use a more systematic quality monitoring system at the last inspection but this does not appear to have been developed across all areas of the home and practices as originally planned. The home does have a basic development plan for the service and in discussion the manager did demonstrate to us a clear understanding of the need to plan business activity and budget. The home takes care of a small amount of money on behalf of some residents. This is used to pay for hairdressing newspapers and toiletries. Individual records are kept of each transaction. There were no records of regular staff supervision having been done so aspects of practice and staff career development needs have not been given attention. Risk assessments are completed and updated by the manager and discussions and the observation of records confirmed that equipment is being maintained and serviced through annual service level agreements. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 23 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 2 X 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 24 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 13 (6) Requirement All care staff working in the home must be fully trained in identifying abuse and ‘Safeguarding Adults’ procedures and this recorded. The registered manager must make sure that there is a consistent and coordinated staff annual training and development programme in operation to make sure care staff receive all the training they need to fulfil their roles. Timescale for action 10/12/07 2. OP30 18 (1) 10/12/07 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 OP1 OP4 Good Practice Recommendations The Statement of Purpose should include the full range of services and support the service gives to residents with dementia and mental health problems. As the service states it provides dementia care all staff working in the home should have up to date training on
DS0000048089.V344904.R01.S.doc Version 5.2 Page 25 The Old Vicarage (Askam) 3. OP7 4. 5. OP9 OP9 6. OP18 7. 8. 9. OP18 OP33 OP36 this. Care plans should be more person-centred and include more in depth information to reflect individual perspectives and support needs for all residents and be clear about specific actions needed for people with challenging behaviours. Where changes need to be handwritten then for good practice to reduce the risk of error staff should have them checked, verified and signed by another member of staff. The safe practice of using protocols for the administration of “when required” medicines should be introduce for all “when required” medication so people receive these medicines only when needed. The manager should carry out a review of the service’s own adult protection procedures as some aspects of their procedures are not in line with local multi agency guidance to protect residents. The registered manager should also get a copy of the Department of Health guidance” No Secrets” to support good practice and inform the homes practices. Staff, and residents meeting should always have minutes taken so the information and outcomes are clear for all concerned. The registered manager should make sure that formal staff supervision takes place allowing staff to address practice matters and career development. The Old Vicarage (Askam) DS0000048089.V344904.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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
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