Inspection on 20/09/05 for The Old Vicarage [Churchill]

This inspection was carried out on 20th September 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 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 [Churchill] 23/10/06

The Old Vicarage [Churchill] 09/01/06

The Old Vicarage [Churchill] 16/03/05

The Old Vicarage [Churchill] 09/08/04

The Old Vicarage [Churchill] 11/02/04

The Old Vicarage [Churchill] 16/06/03

The Old Vicarage [Churchill] 16/06/03

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Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor 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 Front Street Churchill North Somerset BS25 5NG Lead Inspector Caroline Baker Unannounced 20 September 2005 th 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 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 D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Front Street Churchill North Somerset BS25 5NG 01934 853211 01934 853451 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) Mr William Dunnett Jackson Mr William Dunnett Jackson Care Home - Personal Care Only 19 Category(ies) of Old Age - (19) registration, with number of places The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 March 2005 Brief Description of the Service: The Old Vicarage is just off the A38, in the village of Churchill. It is registered with the Commission for Social Care Inspection (CSCI) to provide personal care to up to 19 persons over the age of 65 years. There are 17 single bedrooms and 1 double. All have en-suite facilities and all have a pleasant outlook. Some have french doors onto the garden allowing freedom to explore the well maintained very pleasant gardens. The house is decorated and furnished to a high standard. There is a choice of two lounges and a dining room for service users to socialise. A passenger lift is available for service users to access the first floor. There is an emergency call system throughout. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was unannounced and took place on 16th March 2005. One recommendation was made at that inspection which had been acted upon. This inspection was also unannounced and took place over one day (7 hours) by Caroline Baker. Seventeen service users were residing at the home. The manager was in charge there were two care staff, a domestic, cook and general assistant on duty. Staffing levels appeared adequate. An assessment of the premises took place where all bedrooms and communal areas were seen. All of the service users were consulted with on their views to the care provision at the home. Staff on duty during the morning were consulted with. The registered provider/manager was available throughout the inspection. Visitors were consulted with including a District Nurse, GP and relatives to two service users. Throughout the day the inspector was able to observe interactions between staff and service users. Records relating to the care of the service users, staff and health and safety were examined. What the service does well: The Old Vicarage provides a well-maintained, secure and comfortable environment, which meets the needs of the current client group. Service users were observed using all communal areas and appeared comfortable and relaxed in their environment. Service users spoken to stated that they liked their bedrooms and were happy and felt safe at the home. Service users were well attired and looked well cared for on the day of inspection. Service users praised the food. A good choice of wholesome food was given. Service users are able to live in the way they wish and have a choice of daily living. One service user has their dog at the home, which made them very happy. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 6 Relatives and health care professionals seen on the day of the inspection were complimentary about the provision of care at the home and stated that they were always made welcome. Staff spoken with stated that they felt well supported and happy working at the home. Staff training was well documented and the provision of training for staff is good. Staff acted in a professional manner. Staff and service users praised the support of the manager. The gardens are well maintained and pleasant. Many service users enjoy accessing the gardens. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, and 5. NMS 6 is not applicable to the home. Prospective service users are provided with information to allow them to make an informed choice. The home takes appropriate steps to ensure the needs of prospective service users can be met prior to a decision being made about admission. All service users receive terms and conditions of stay. EVIDENCE: Evidence was seen that each service user is given a brochure, Service User Guide and Statement of Purpose on admission to the home and through enquiry. This includes a terms and conditions of stay document. Service users can visit the home prior to admission to assist any decision to live there. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 9 Evidence was seen in the two of the resident files sampled that a full preadmission assessment had been undertaken to ensure the home could meet individual service users needs prior to admission. Staff individually and collectively had the skills and experience to deliver or assist with the services and care the home offers to provide. Evidence was seen through displayed certificates, and staff training records. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, and 10. Although each service user had a care plan the processes needed improving and there was no evidence of service user input. The privacy and dignity of service users was respected. The homes procedures for the management, administration, recording and disposal of medication, potentially placed service users at risk of harm. EVIDENCE: Three care plans were sampled and the individual service users spoken with as part of the case tracking process. The care plans had been reviewed on a monthly basis. There was evidence that service users were weighed monthly. Preferred names and times of rising and going to bed were recorded. Two out of three care plans detailed the current care needs of the service users. One care plan did not reflect an individuals needs in regard to treatment of a pressure ulcer or the pressure relief used. None of the care plans identified manual handling needs and evidence was seen that one of the service users overnight needed regular turns which had not been documented as a care need. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 11 None of the care plans reflected overnight needs and social histories had not obtained. Service users at risk of falling did not have a risk assessment completed with detailed actions to be taken reflected to prevent falls. There were no pressure area risk assessments or nutritional assessments recorded and these should be obtained and recorded on admission to allow any changes to be identified. There was no evidence seen of service user involvement. The service users have access to health care professionals on a regular basis. A District Nurse and GP were seen visiting on the day of inspection. It is recommended that a separate professional visit form is completed and kept in the care plan for easy access, rather that record each visit on the daily records which are filed away regularly. Service users able told the inspector that they had access to chiropody visit and eye tests. A GP surgery provides a pharmacy service to the home. The medication systems were assessed and discussed with the manager. Findings concerned the inspector as to the safety of the systems in place for example some controlled drugs were not entered in the CD register and running totals were not recorded. Received medications were recorded but not signed for. Medications were re-dispensed from bottles into nomad type trays twice weekly; this meant that staff could not identify the medications given. One service user told the inspector that they only took half a prescribed medication tablet, the home had not recorded this and no evidence was found of the other half of the tablet. On assessment of the premises prescribed creams were seen in some bedrooms, which had expired in 2002, 2003 or 2004. This was brought to the attention of the staff and manager and expiry dates and writing opening dates on creams were discussed. Given these findings the inspector informed the manager that the local CSCI pharmacist inspector would be asked to visit the home to give advice on their medication systems and policies. Service users complimented the staff group and informed the inspector that they were always treated with respect and that their privacy was respected. Service users were able to lock their doors if they wanted to. Staff were heard knocking on doors before entering and spoke to service users in a kindly and respectful manner. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. The home’s arrangement for meeting service users social needs was adequate. Service users benefited from a wholesome diet. Serviced users dictated the routine at the home by their choice of daily living. EVIDENCE: Activities are provided on a daily basis by the staff on duty. On the day of inspection the service users were preparing to play bingo in the afternoon. Other activities available included manicures, scrabble, walks to the shops and walks in the garden, flexercise and sing-a-longs. The majority of service users felt that the activities at the home were adequate, some expressed a wish for more. The manager told the inspector that a record was not kept and this is recommended. As previously mentioned a social history and record should be reflected in individual service users care plans. All the service users complimented the provision of food at the home. A choice was available and service users are asked on a daily basis their choice for the next day and a record was maintained. The lunchtime meal was observed. It was well presented and looked appetising. The atmosphere was unhurried and The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 13 dignified. Tables were laid to a high standard and the dining room décor and furnishings were of good quality. Relatives were seen visiting the home during the inspection and they were able to visit the service users in private. Those spoken to indicated that they were more than satisfied with the provision of care at the home. Service users were seen enjoying the garden and others were seen being escorted to the nearby shops. All service users able told the inspector that they were able to choose times of getting up and going to bed and what they did during the day. It was evident that service users quality of life was important to the home; they were able to personalise their rooms and bring in their own possessions and one service user had been able to bring their dog with them. Service users were encouraged to handle their own financial affairs. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system in place. The home’s recruitment procedures for staff did not protect service users from the potential risk of abuse. EVIDENCE: Service users, staff and relatives spoken to were aware of the homes complaint procedure and who to talk to with any concerns. The procedure named was displayed in the entrance hall and is found within the service user guide. The home had not recorded any complaints since the last inspection and the CSCI had not received any against the home. The home had the local ‘No Secrets’ multi-agency policy on Safeguarding Vulnerable Adults. The home had a Whistleblowing Policy, which is comprehensive and details outside bodies that staff can approach. Staff spoken to on the day of inspection knew about the Whistleblowing Policy and lines of communication to be taken if necessary. Service users may access their personal financial records, if they wish to do, so at any time. Service users spoken to stated that they felt safe at the home. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 15 The home uses MG Care Executive as its CRB umbrella body to obtain enhanced CRB disclosures. Three staff recruitment files were examined as part of the inspection and issues were raised that compromised the protection of vulnerable adults as detailed later in the report. The manager admitted that he was unsure of POVA. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Service users live in a safe and comfortable environment, which is able to meet the assessed needs of service users living there. Service users have access to specialist equipment where there is an assessed need. There were no malodours in the home; the standards of cleanliness were very good. Infection control measures were inadequate. Records of hot water outlets being tested to ensure in line with HSE guidelines were not maintained potentially putting service users at risk of harm. EVIDENCE: The home is decorated and furnished to a very high standard and carpets identified as needing replacing at the last inspection had been. There were further plans to re-carpet the main hall and lounges. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 17 About a third of the bedrooms are on the ground floor and have French windows onto the garden. There is a pleasant lounge opposite the dining room that also has French windows onto the garden. Another seating area is in the corridor outside the conservatory and in the conservatory itself. Each bedroom has an en-suite toilet and 3 have en-suite baths, which are not used by the current service users. There is a communal toilet on the ground floor, close to the lounge and dining room. There are 3 communal bathrooms around the home (one is not in use the inspector was told) one of which has a walk-in bath with overhead shower. The majority of service users use the upstairs communal bath with a portable bath hoist. The manager informed the inspector that thermostatic valves were fitted to the bath hot water outlets. Hot water temperature records or bath temperatures were not recorded and this is required as one of the communal baths were running at over 50oC and it should be 44oC in line with HSE guidelines. Bedrooms are all of a good size and are equipped to meet service users individual needs. Each is equipped with a digital keypad safe to enable service users to store medication, monies or valuables. The fire officer and environmental health department had not visited the home in the past two years. The cleanliness of the home was very good at this inspection. Hand washing facilities for staff were not available where personal care was provided including communal baths and this is required to control any spread of infection to include liquid soap and paper towels. Staff informed the inspector that alcohol gel was sometimes available and that they could wash their hands in the staff toilet, which was downstairs. This is inadequate. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, and 30. The home’s recruitment procedures for staff were not robust and did not protect service users from the risk of abuse. The numbers and skill mix of staff were not appropriate overnight to meet the needs of current service users. Staff morale was very good. EVIDENCE: The home records a duty rota on a weekly basis and the rota reflected the staff on duty apart from the manager’s day shifts, which is recommended. The manager and his wife live in a house next to the home and are on call overnight. The manager was in charge of the home at the time of the inspection. There were two care staff, a general assistant, a cook and cleaner on duty. During the afternoons there are two carers. The care staff also undertake activities and laundry duties. Overnight there is one carer who is responsible to deliver any personal care required to service users, some cleaning chores, preparation of vegetables and ironing. It was also evident from records kept within the individual service user files that carers overnight are turning service users on their own. This must cease. If a service user requires turning two persons must attend in line with Moving and Handling Regulations and equipment such as ‘multiglides’ must be available. The home does not have a mobile hoist and this is recommended if The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 19 only for emergency use. Not all staff had received formal moving and handling training in the past 12 months and this must be arranged. The manager must review staffing at the home and ensure that there are two persons available should a service user require turning overnight. The manager informed the inspector that his deputy was no longer working at the home and discussed the provision of another deputy manager being employed. Staff morale was good and staff told the inspector that they were happy at the home and that they felt staffing levels were adequate. The majority of service users felt that staffing levels were adequate three were concerned that only one member of staff was at the home overnight, however they also said that the manager would come over in an emergency. They said they were happy with that arrangement. Three staff recruitment files were examined as part of the inspection process. The following issues led to an immediate requirement notice to not employ any further staff without the following being served: • • Only one written reference was available for one person – one person had just commenced employment and two had worked at the home for 12 months And enhanced Criminal Record Bureau (CRB) disclosures and/or POVAFirst checks had not been sent for before employment for all three. This was discussed at length with the manager who agreed to update himself on the POVAFirst checks and undertake a full audit of all the staff files to ensure all items required by legislation were available for the protection of vulnerable adults. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 34, 36, 37 and 38. The registered provider/manager continues to manage the home in an open approachable way. Staff training is promoted. The systems in place for ensuring the health and safety of service users needed improving. EVIDENCE: The registered manager is Mr W Jackson who now has more responsibility since Louise his deputy has stepped out of the home to further her career. Mr Jackson is responsible for the implementation of the homes policies in respect of all the care home’s services and management of staff and all tasks in line with the Care Standards Act 2000. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 21 Given the findings at this inspection it is evident that the manager must undertake an audit of the systems in place that have been identified as needing attention for the safety and protection of the service users at the home. It was evident having spoken to staff and service users on the day of inspection, that the manager communicates a clear sense of direction, and leads the staff in a way that they understand. They said he was approachable and open, and the staff indicated that they were well supported. Staff had received formal supervision at least once this year and records were seen in the staff files examined. These should be signed and dated and be up to at least six times per year. The remaining records seen at inspection were up to date and in line with current legislation. All service histories were current. The fire records were examined; the home had conducted weekly fire and emergency light checks up until 01/09/05. Staff had been given fire safety training on a monthly basis last on 25/08/05. Fire equipment and emergency lighting annual checks were overdue. Gas servicing was up to date. PAT testing was up to date. Only one accident had been recorded since the last inspection, however on assessment of the care plans sampled three falls had been recorded in the daily records of two of the service users one being serious leading to a fracture and this had not been reported to the CSCI or RIDDOR in line with regulations. The manager told the inspector that it was his responsibility; it was recommended that staff be given the responsibility as they are the ones who mainly discovered the falls. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 x 3 x 3 3 1 The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 23 NO 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. Standard OP7 Regulation 15 Requirement Individual plans of care must reflect current care needs to enable care staff to deliver the care effectively and where possible evidence of service user input must be reflected. The registered person must review the medication systems urgently, to ensure they are safe and in line with the Royal Pharmaceutical Guidelines. All prescribed creams must be dated and discarded when out of date. The registered person must update themselves in regard to POVA. All staff must receive formal abuse awareness training. All hot water outlets must be regularly monitored as to the temperature, and records maintained in line with HSE guidelines. Hand washing facilities must be provided for staff in areas where personal care is provided to include liquid soap and paper towels. The registered person must not allow one member of staff to Timescale for action 1st October 2005 2. OP9 13(2) 1st October 2005 3. 4. 5. 6. OP9 OP18 OP18 OP25 13(2) 10 13(6) 13(4)[a] and [c] 1st October 2005 1st October 2005 30 January 2006 1st October 2005 7. OP26 13(3) 15 October 2005 8. OP27 13(5) 1st October Page 24 The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 turn service users without help and must review service user dependency levels and staffing levels plus equipment availability without delay. Formal Moving and Handling training must be arranged for those staff who have not received it in the past 12 months. The registered person must not employ a person to work at the care home without all the information listed in Schedule 2 and 4 (6) of ther Care Home Regulations 2001. An immediate requirement notice was issued. Fire alarms must be tested on a weekly basis. All wardrobes must be risk assessed and/or secured to prevent risk of harm to service users and all first floor windows must be restricted in line with HSE guidelines. An immediate requirement notice was served. All accidents that happen in the care home must be recorded appropriately and if serious must be reported to the CSCI and RIDDOR. 2005 9. OP29 17(2) and 19 20th September 2005 10. 11. OP38 OP38 23(4)[c] 13(4)[a] and [c] 1st October 2005 20th September 2005 12. OP38 17(2) Schedule 4 12[a] and [b] 1st October 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. Refer to Standard OP7 Good Practice Recommendations Individual care plans should contain a social care need plan, moving and handling risk assessment, pressure area D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 25 The Old Vicarage 2. 3. 4. OP12 OP38 OP38 risk assessment falls assessment, nutritional assessment and a professional visits format. The activities programme should be revised with input from service users on an individual basis. Care staff should be given in-house training on reporting and recording of accidents and should be encouraged to do so. The home should purchase a mobile hoist. The Old Vicarage D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 D53-D02 S8065 The Old Vicarage V225219 200905 stage 4.doc Version 1.30 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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