Inspection on 02/08/05 for The Old Vicarage [Blakeney]

This inspection was carried out on 2nd August 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Vicarage [Blakeney] 17/05/07

The Old Vicarage [Blakeney] 10/10/06

The Old Vicarage [Blakeney] 06/12/05

The Old Vicarage [Blakeney] 15/03/05

The Old Vicarage [Blakeney] 10/12/04

The Old Vicarage [Blakeney] 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Vicarage Church Square Blakeney Nr Lydney Gloucestershire Lead Inspector Lynne Bennett GL15 4DS Announced 2 August 2005; 10:00 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 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 Stationary 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 D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Church Square Blakeney Nr Lydney Gloucestershire GL15 4DS 01594 517098 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stepping Stones Resettlement Unit Ltd To be appointed Care Home - Care Home only 13 Category(ies) of Learning Disability (LD) - 13 registration, with number of places The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15th March 2005 Brief Description of the Service: The Old Vicarage is owned by Stepping Stones Resettlement Unit Ltd which owns four other homes in the area. The organisation has been awarded the ISO 9002 award and has retained the award in subsequent years. The Old Vicarage is a Grade 2 listed building and provides residential care for 13 people with a learning disability and a history of challenging behaviour. The accomodation is provided in the main house,the nearby Coach House and in a self contained flat. The main house accomodates eight people over three floors. All have single rooms with en suite facilities. Four people live in the Coach House across the courtyard. They have single rooms with the use of a bathroom and a shower room. One person lives in the flat. To the rear of the properties are well maintained gardens. At the front of the main house there is a garden overlooking the village. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours on a day in August 2005. A tour of the main house and coach house was conducted with the acting manager. Several people living at the home showed the inspector their rooms in the main house. Time was spent talking to seven people living at the home and to three members of staff. The care of three people was case tracked. This involved looking at their care plans, personal information, medication and financial records. They were spoken to about the home and there were discussions with staff about their care. Other records examined included staff files and health and safety information. A pre-inspection questionnaire was completed and Regulation 26 reports (quality assurance visits) provided by Stepping Stones are taken into account. Comment cards were received from twelve people living at the home, two parents and a health and social care professional. Telephone comments were received from another two parents. What the service does well: What has improved since the last inspection? Information kept on people’s personal files has improved and is regularly reviewed. Their care plans are improving showing that they are being involved in setting their goals and action plans. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 6 Staff ratios have improved over the weekend enabling people to occasionally go out for lunch or shopping and to fetes. People living at the home say they enjoy the range of holidays and short breaks offered. Staff are being scheduled for supervision sessions every 8 weeks and staff meetings are taking place each month. Staff say that this has improved communication and team working. What they could do better: 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 Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4, and 5. The home’s Statement of Purpose and Service User Guide give prospective people moving into the home details of the services the home provides. A series of visits enables them to make an informed choice about whether they wish to live there. There was no evidence that people living at the home are aware of the statement of terms and conditions with the organisation. EVIDENCE: The home has a Statement of Purpose and Service User Guide that are regularly reviewed. Each person has a statement of terms and conditions. On the files examined one had not been completed and another was for the person’s former residence at another home in the group. None of these documents are signed or dated. All people living at the home must have a statement of terms and conditions in place for The Old Vicarage. The home will shortly have a vacancy and has been assessing prospective admissions. Presently a person living at another home in the group is visiting the home with a view to moving in. This person has already visited for a short visit and will be having a tea visit. Information will be supplied to the home prior to the move. The acting manager has visited the person at their present home and met with other professionals involved in their care. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 9 A person moved into the home in March this year. Visits were completed prior to the move. This person had lived at the home previously and requested to return there. The person confirmed that they were happy living at the home and liked their room. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9. Care planning in the home is improving thereby promoting the development of skills and independence. Risk assessments encourage and support people living at the home to challenge and deal with problem areas in their lives. The systems for consulting people living at the home in aspects of their daily life could be improved creating greater opportunities for involvement. EVIDENCE: The care for three people was case tracked. This included a new person living in the main house and two people living in the coach house. The progress towards completing their care plans was inconsistent. There was no evidence of who was compiling the plans and the dates when plans were being developed. Plans must indicate the author and the date when the plan was developed. This is still a work in progress. It is expected that this will be completed by the time of the next inspection. One plan is written in the first person. This is good practice. Other information contained in the files is current and is regularly monitored and reviewed. Each person has a current Pathways to Independence assessment in place. It is evident that developmental plans are being derived from an assessment of needs provided by the placing authority. Copies of the annual reviews for the The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 11 three people sampled are in place. Reviews are being requested for others living at the home. There are good examples in some of the developmental plans of how people living at the home are being supported to become more independent for instance crossing roads and going out unsupervised either to the village or around other towns. At previous inspections concerns have been raised about the use of sanctions for one person. Those in question are no longer in place. Sanctions for another person indicate that the number of cigarettes smoked in a day is restricted. The care plan does not clearly state the reasons for this. Where the plan identifies this is for health reasons additional evidence must be included to verify the basis for this, (e.g., as advised by the doctor and with the consent of the person). People living at the home have the occasional house meeting. Minutes for a meeting in May showed good attendance. Feedback from some of the comment cards indicated that people living at the home would like to have more involvement in the running of the home. Some people said that they have responsibility for day-to-day chores such as cleaning and washing. A quality assurance survey was last completed in 2003 and this must be repeated with an emphasis on how people can be involved more in the running of the home. For instance, people living at the home are not involved in the recruitment and selection of staff. Risk management plans are in place for risks and hazards identified in the development plans. These are being reviewed regularly and are signed. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16 and 17. A varied programme of social and recreational activities is scheduled that may occasionally be restricted due to inappropriate staffing levels and access to drivers. Contacts with families and friends are being encouraged. A range of meals is provided reflecting the cultural diversity of people living at the home and enabling a healthy diet. EVIDENCE: People living at the home have access to a range of daytime activities. One person said they enjoy working with horses. Others are being registered to attend a variety of college courses in the autumn. Most people attend Stepping Stones day service nearby. On the day of the inspection they had enjoyed painting and pottery. One person said they liked crafts and showed a selection of prints and pottery they had created. One person chooses not to attend day care spending time at home. They said they liked to do tapestry, watch films, listen to music and go out for lunch. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 13 People living at the home use facilities in the village and local towns. Several said they look forward to trips to Gloucester for shopping and a meal out. They have access to a car and mini bus and also use local transport. It is hoped that two people carriers will be purchased that all staff will be able to drive and so creating greater access to activities. There continue to be concerns that the staffing rota at weekends may be insufficient to support people to fully access community activities, despite significant improvements in the ratios of staff on shift at these times. (See Standard 33) People enjoyed holidays to Blackpool and Greece earlier this year and are already planning the next trip to Blackpool. People are supported to maintain contact with family and friends. One person said they visited their family the previous weekend. They also have access to the home’s phone. Favourable comments were received from family members some saying they visit the home several times a year and all indicating that they can visit in private if they wish. People were observed choosing where to spend their time and with whom. They are able to make drinks and snacks if they wish. Some people help with the cleaning and washing. Staff have a good understanding of the likes and dislikes of people living at the home and their daily routines. On the day of the inspection a lunch of cheese or ham sandwiches was provided. One person chose to have beans on toast. The evening meal was a baked potato with either tuna or cheese and salad. This appeared to be greatly enjoyed. Comment cards indicated that not all people were satisfied with the meals being provided. Alternatives are available to the main meal option. People spoken to during the inspection said they enjoyed the meals. The dietary needs of one person are being monitored. The cultural needs of one person are respected in the selection of meals made available. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20. People living at the home have access to a range of healthcare professionals making it possible to meet their physical and emotional health needs. Systems for the administration and control of medication are not satisfactory and there needs to be improvement to ensure that people living at the home are not put at risk. EVIDENCE: A Health Action Plan is being introduced in the home that will provide comprehensive information about each person’s healthcare needs. People are registered with a local GP and have regular appointments with their dentist, optician and chiropodist. One person living at the home said they had seen their optician the day before, another had visited the dentist and another person said they regularly visited the doctor. People are supported to attend outpatient appointments and referred to health and social care professionals where appropriate. Good records are being maintained. Most of the medication is dispensed in a monitored dosage system with some additional medication being provided. The following issues must be addressed: • Medication must not be removed from the container in which it was dispensed The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 15 hand written entries on the medication administration record must be signed and should be countersigned • a homely remedies list must be drawn up for approval by the pharmacist • a stock control record must be put in place for PRN or as required medication. Staff attend medication and epilepsy training. They have also completed training in the use of buccal midazalam. Protocols are in place for the use of PRN medication. • The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home’s system for monitoring complaints could be improved providing easy access to information. The home is protecting people living there from abuse by providing appropriate training for staff and having good systems in place for the administration and control of their personal finances. EVIDENCE: The home has a complaints policy and procedure that needs reviewing to reflect the changes from the NCSC to the Commission for Social Care Inspection and changes within the home. Information displayed in the home is up to date. Although records of complaints are kept these are not stored apart from incident records. A separate complaints log or section to this folder must be put in place for the storing of complaints and the recording of their outcome. Staff have a good awareness of the protection of vulnerable adults. Training is being provided by Stepping Stones and the home has access to the alerter’s guide. Financial records are kept for personal income and expenditure including disability living allowance. Balances in individual purses agreed with balances on the records. It is recommended that receipts are cross referenced with the records and archived with each month’s record to help with checking and minimising errors. People subscribing to Sky television pay for this each month at the local post office. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. The environment is homely and comfortably furnished. There is an ongoing maintenance and refurbishment programme in place making sure that the home continues to meet the needs of the people living there. EVIDENCE: The Old Vicarage is a listed building and any exterior work must be completed in line with regulations for listed buildings. Since the last inspection new windows have been fitted to the back of the property. One person living in the home said they were delighted with the new windows. Windows to the front of the building require some attention and this was identified in a recent Regulation 26 report. The exterior of the building has been redecorated and ivy removed from the side of the house. It is evident from the general maintenance records and Regulation 26 reports that the environment is regularly monitored and any issues dealt with promptly. Plans to refurbish the kitchen in the Coach House are still in place. This kitchen is used for the preparation of snacks and drinks. Meals are brought over from the main house. It is envisaged that people living in the Coach House will eventually prepare their own meals. One wall of this kitchen needs treatment for damp. The organisation should consider when they are going to implement the refurbishment of the kitchen. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 18 Each person has a single room some with en suite facilities of a toilet and washbasin. Rooms seen were pleasantly decorated and reflected the lifestyles and interests of the people living there. They have access to a large comfortable lounge and dining room. Pictures created by people living at the home adorn walls around the house. People living at the home were observed choosing where to spend their time and with whom, accessing all communal areas including the front garden. During a tour of the building several environmental issues were noted which must be dealt with: • • • • • • several door knobs are loose, this must be rectified the carpet on the ground floor rear bedroom must be cleaned or replaced a handle on the vanity unit in this room is missing, this must be replaced dining room chairs are stained, these must be cleaned or covered (the acting manager confirmed that a steam cleaner was being hired to clean carpets and the chairs) paper towels must be available in communal washbasins the damp on the wall in the kitchen in the Coach House must be treated. At the time of the inspection the home was clean and tidy. The acting manager has consulted with Environmental Health about the positioning of the freezers in a room inside the laundry. They have confirmed that this is satisfactory. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34, 35 and 36. The numbers of staff on duty do not always reflect the needs of people living at the home restricting access on occasions to community activities. Robust recruitment and selection procedures are in place promoting the safety of people living in the home. Staff have access to a range of training providing them with the knowledge and skills to meet the needs of people at the home. EVIDENCE: At previous inspections concerns were raised about the levels of staff at evenings and weekends. There has been a significant improvement. Staff confirmed that there are three staff present until 8.00 pm each evening reducing to 2 staff until 10.00 p.m. If required the third member of staff will remain until 10.00 p.m. At weekends there are now 3 members of staff on duty. It is still felt that these ratios do not provide sufficient cover for the group of 13 if people wish to go out in a small group and others want to remain at home. This will continue to be monitored. The acting manager has increased the daytime cover for those people who do not wish to attend day care so that they can have support to access other activities. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 20 Staff spoken with have a good understanding of the needs of people living at the home and how they should be supported. They say they are able to access a comprehensive training programme from induction including the Learning Disability Award Framework to the NVQ Programme. Training specific to the needs of people living at the home is provided such as autism awareness and courses in epilepsy and diabetes. Staff have recently attended training courses in fire, moving and handling and self harm. Certificates are kept on their files. Basic food hygiene training is planned for September 2005. This is overdue for most staff. A training matrix identifying courses attended by staff was out of date. It is recommended that this be reviewed so that the acting manager can easily monitor when refresher training is due. Courses available for September were displayed in the home and these included the Protection of Vulnerable Adults training. There have been no new staff employed by the organisation since the last inspection. One member of staff was transferred from another home. Her file and the files of two other staff were examined. All files contained the correct information as required under Schedule 4. It was noted that on one file two different reference requests were used. The organisation has changed the reference request to comply with changes in the regulations (July 2004) and must ensure that this form is sent out to referees. The acting manager was advised to dispose of any CRB checks still on file. This was done during the inspection. At previous inspections concerns had been expressed that staff meetings and supervision sessions for staff were not in place. Staff said that they have regular staff meetings and supervision sessions are being scheduled. Two team leaders have completed training in supervisory skills and will be sharing responsibility with the acting manager. Staff felt that communication within the home was good and that the team were working well together. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 40 and 42. The acting manager needs to ensure that he has the necessary qualifications to support people living at the home and the staff group. There needs to be an improvement in health and safety systems to ensure that people living at the home are protected from environmental risks and hazards. EVIDENCE: The acting manager has applied to the Commission to become the registered manager for the home. He has considerable experience supporting people with a learning disability. He has not registered for the Registered Managers Award or completed the NVQ in Care at Level 4. This must be put in place. He has completed an Introductory Certificate in Team Leading. Staff spoke positively about the acting manager saying that they felt he would challenge poor practice. The acting manager is delegating responsibility for staff to undertake key health and safety tasks. He confirmed that they would be doing the necessary training. Health and safety records were examined and together with the preThe Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 22 inspection questionnaire confirmed that monitoring systems are in place. The following issues must be actioned: • • • fire systems and equipment are being monitored although not always at correct intervals. Fire alarms must be tested weekly. Portable appliance testing is due. The general maintenance team are currently completing training and will then carry this out. Water temperatures are being taken – when they register above 43 C any action taken must be recorded. It is recommended that the safe parameters are indicated on the records. It is recommended that temperatures are taken each month from a sample of outlets instead of every three months, so that temperatures can be regularly monitored. Fridge and freezer temperatures are recorded and regularly indicate temperatures outside of safe parameters. The records should indicate these and note action taken. • Accident and injury records are being kept. These must be stored securely. All other records are stored appropriately and information is archived as necessary. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Old Vicarage Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x 2 x 2 x D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? 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. 2. Standard 5 6 Regulation 5(1)(c) 15(1)(2) Requirement All service users must have a statement of terms and conditions. Revise and update all care information on service users files in line with the person centred approach. (Timescales of 30/4/05 and 30/6/05 not met) Plans must be dated and reviewed regularly. Provide evidence for the sanction in place as identified in the standard, recording evidence of consultation with individuals and other significant people involved in their care as to whether these are in their best interests. Systems must be put in place for regular consultation with services users and to enable them to make decisions the care they are receiving. Including the quality assurance questionaire. Medication systems must be put in place as indicated in the standard. The complaints policy and procedure must be amended as indicated in the standard. A complaints log must be kept. Environmental issues as Timescale for action 2 October 2005 30 October 2005 3. 7 12(2) (3) 17(1)(a) Sch 3(3)(q) 2 October 2005 4. 8 12(2)(3) 24(3) 30 October 2005 5. 6. 20 22 13(2) 17(2) 2 October 2005 2 October 2005 2 October Page 25 7. 24 23(2) The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 8. 9. 34 37 19(1)(b) Sch 2.4 9(1)(b)(i) 10. 11. 12. 40 42 42 17(2) Sch 4.12(a) 23(4)(v) 13(4) identified in the standard must be addressed. The reference form requesting writted verification for leaving a position in care must be used. The acting manager must undertake the Registered Managers Award and NVQ Level 4 in Care or recognised equivalent. Accident records must be stored securely. Fire alarms must be tested each week. Water temperatures must be maintained at 43 C or under for all outlets excluding the kitchen. Fridges and freezers must be maintained at the correct temperatures. 2005 2 August 2005 31 Dec 2006 2 August 2005 2 August 2005 2 Sept 2005 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. 3. 4. 5. Refer to Standard 5,6,9 23 28 35 42 Good Practice Recommendations Service users should sign plans and other records where appropriate. Receipts should be cross referenced with records and archived each month. The kitchen in the Coach House should be refurbished. The training matrix should be reviewed. The safe parameters for temperatures for water outlets and fridges/freezers should be indicated on the record sheets. A sample of water outlets should be tested each month. The Old Vicarage D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 26 Commission for Social Care Inspection 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 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 D51 D03_s16626 The Old Vicarage v216528_Stage4_020805.doc Version 1.40 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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