Inspection on 23/10/06 for The Old Vicarage [Churchill]

This inspection was carried out on 23rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Vicarage [Churchill] 09/01/06

The Old Vicarage [Churchill] 20/09/05

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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Belma

Hunters Care Centre

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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 Catherine Hill Unannounced Inspection 23rd October 2006 09:25 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 DS0000008065.V312623.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 DS0000008065.V312623.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Front Street Churchill North Somerset BS25 5NG 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) 01934 853211 01934 853451 Mr William Dunnett Jackson Mr William Dunnett Jackson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Old Vicarage is just off the A38, in the village of Churchill. It is registered to provide personal care to up to 19 people 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 main lounge and a conservatory area as well as a dining room. A passenger lift gives access the first floor. There is an emergency call system throughout. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the course of one day and lasted approximately 6 hours. The inspector spoke with 12 of the residents, most of them privately and in depth. She also spoke with some of the staff on duty, and spent time with the senior staff member in charge of the home. This was a key inspection, which means that most of the National Minimum Standards were checked. The CSCI Pharmacy Inspector visited the home in October 2005, and the inspection today also looked at how her requirements and recommendations have been carried out. Records sampled included: • residents care records • residents contracts • menu records • medications records • staff rotas • staff recruitment and training records • the homes maintenance log and records of safety checks • residents and relatives questionnaires • records of accidents • fire precautions testing records and the Fire Risk Assessment The inspector also did a tour of the premises. What the service does well: As at previous inspections, residents were highly satisfied with every aspect of the service they receive. From the comments they made, it is evident that the staff team has not rested on their laurels but has identified ways of even further improving residents quality of life. Many people told the inspector how kind, flexible and reliable the staff are, and heaped praise on the cooks for the quality of meals provided. Newer residents said that it is the staff who helped them to feel settled and comfortable so quickly. Several people made comments such as ask for anything, theyll do it and we are spoilt. One person said: This isnt me being here with people looking after me: Im here with friends. Another said this is a happy, happy place. The service is highly individualised. For example, each resident has their own fire procedure that is posted on the back of their bedroom door and has been tailored to their individual circumstances, such as how mobile they are and whether they have a pet in their room. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 6 The environment is particularly pleasant and well-suited to residents needs. All rooms are single and ensuite, and seven of them are ground floor rooms. Six bedrooms have French doors leading onto the garden, which is very pretty and secluded. Communal rooms are attractive and comfortable. What has improved since the last inspection? What they could do better: A couple of minor adjustments to medications records and storage are needed. Most chemicals are stored safely, but care must be taken to ensure that all hazardous chemicals are locked away when not in use. Communal toiletries, particularly items such as razors, must not be used. Staff covering night-time duties need to have fire refresher training every three months. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Vicarage DS0000008065.V312623.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 DS0000008065.V312623.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality outcomes in this area are good. Prospective residents get enough information to make an informed decision about moving into the home, and the home gathers enough information on them to be reasonably sure of meeting their needs. EVIDENCE: The Statement of Purpose gives clear and succinct information about the home. Fees are negotiated on an individual basis. The pre-admission assessment gathers information on all significant areas of need, and about the persons preferences. Staff ask the person for more detail about preferred routines and foods soon after admission. Each resident’s file has a copy of the home’s Terms and Conditions or a contract. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 10 New residents said that they had been made to feel really welcome, and that staff had sat with them and asked about how they like things. The home does not provide intermediate care. The Old Vicarage DS0000008065.V312623.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality outcomes in this area are good. Many aspects of the care are excellent but there are still some aspects of medications practice and storage that need to be improved. EVIDENCE: An initial care plan and risk assessments are drawn up on the day of admission, in conjunction with the resident and their relatives if possible. The resident or their relative signs these documents. A manual handling profile is also completed. Nutritional assessments and other significant information are gradually compiled as staff get to know the person and their needs. The resident or their relative are asked to check these documents on any updates. Night staff draw up a written night care assessment, which looks at issues such as the number of pillows the person likes, and factors affecting their sleep pattern. Daily notes on each resident were full of useful information. Staff have started compiling social profiles on the residents, with information about significant life events and previous interests, family trees, and preferred daily routines. Residents are asked about their wishes in the event of their The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 12 death, and this is recorded with their care plan information. The inspector suggested that they are also asked about their wishes in the event that they require resuscitation. Residents described support with personal care being given in an understanding manner and at their preferred pace. One person told the inspector how staff had helped them rebuild confidence and regain independence by offering them extra support when they needed it. There have been two serious medication errors reported by the home to CSCI in the past year. The owner has revised the home’s medications procedure on several occasions, has liaised with the supplying pharmacist and with the CSCI Pharmacy Inspector, and has provided training for all staff since then. The medications policy spells out each step of the required procedure very clearly, and underlines the importance of following the correct procedure. It also reminds staff of their individual responsibilities. A copy is now taped to the top of the medications cupboard so that staff can easily remind themselves of the required procedure. The medications cupboard is now secured to the wall, in line with the advice given by the CSCI Pharmacy Inspector. The care manager visits the home unannounced at different times of the day to ensure that all staff are following medications procedure and good practice guidance. She confirmed to the inspector that staff are now no longer handling residents medicines with their bare hands. The home now uses a Monitored Dosage System, and a check of the medications held and the records of medicines administered showed that this system is helping to reduce inconsistencies in the records. It is likely that the system is also reducing the chance of medicines being wrongly administered. Records were generally clear and a photograph of each resident is kept with their (MARS) Medication Administration Record Sheets. However, there were some significant gaps on these records. All of these were for medicines such as an inhaler and prescribed creams, which are likely to be administered to residents separately from the other types of medication. There was no evidence to indicate that these medicines had not actually been administered, so it is likely that staff are simply forgetting to sign the record. This could be a significant oversight, particularly in respect of medicines such as laxatives, so the inspector reminded the care manager of the requirement to maintain accurate records. Residents who self-medicate sign a disclaimer. The person who is given medicine to take later in the day signs the MARS themselves. Vitamins are offered to residents with their medications as an optional extra provided by the home. The care manager has asked residents GPs to do a list of the home remedies that may safely be offered to each person. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 13 Controlled drugs are currently kept in a digital safe. These must be kept in a locked cupboard which is bolted to the inside of another locked cupboard, which in turn is bolted to the wall. This should have been raised with the supplying pharmacist as soon as staff became aware that storage did not comply with current guidance, and now needs to be addressed as a matter of urgency. One of the digital safes was not working during this inspection, which meant that staff could not get access to keys for the residents archived records. The inspector pointed out that, if the other digital safe were to break, the resident who is on a controlled drug as a painkiller could have an unacceptable wait for the next dose. The home aims to provide care for life, wherever possible, and has built effective working relationships with local GPs and district nursing teams to ensure that residents receive the level of care they need in their final days. The staff team also communicates regularly with families, ensuring that they are fully involved and kept up-to-date with changes. Other residents in the home had also been kept appropriately informed, and this had evidently been very reassuring for them. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 12, 13, 14, 15 Quality outcomes in this area are good. There is a range of regular activities on offer, and the homes culture helps people to follow their own preferred lifestyles. EVIDENCE: The activities record had lapsed at the time of the last inspection, but is being kept again. This showed that a good variety of activities is offered, and many of the residents that the inspector spoke with confirmed this. Residents key worker notes also contain a lot of information about one-to-one activities and outings. One of the staff works a regular shift when she devotes her time entirely to having one-to-one talks with the residents. Several people mentioned this as a source of particular enjoyment. Residents also enjoyed the regular visits from the reminiscence lady. Residents that the inspector met on previous visits have been warm in their praise of the home, but the levels of satisfaction at todays visit were even higher. The team has spent a lot of time looking at areas where it can make further improvements to the service, and this is evidently meeting with success. One person said its a happy, happy place. Several people made comments such as ask for anything, theyll do it and we are spoilt. Another The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 15 person said: This isnt me being here with people looking after me: Im here with friends. Residents visitors are given a warm welcome, and they are kept up-to-date with any significant events. A copy of each persons care plan is in their ensuite toilet, so that they can share this with relatives if they choose. Staff try to work with relatives, to ensure that the resident benefits from a consistent approach. For example, one resident has a communication board in their room which is completed by both staff and their visitors. Many residents told the inspector how good the food is, and how willing the cooks are to accommodate their individual tastes. Residents are asked about their ideas for menus, and there are always a couple of choices listed. However, several people told the inspector that there is never any problem with them asking for something different. The menu records showed a really interesting variety of well-balanced dishes. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 16, 18 Quality outcomes in this area are good. Any concerns are taken seriously and promptly addressed. Staff are alert to the potential for abuse. EVIDENCE: No complaints have been received by the home or by the CSCI since the last inspection. The home’s complaint procedure is clear and welcoming, and includes information on timescales and follow-up actions. The whistle-blowing procedure emphasizes staff’s duty to report concerns. The complaints book used to be kept in the hall, and the care manager has been considering returning to this practice. The inspector suggested that complaint forms and envelopes are provided instead, as this allows any complaints to remain confidential. One resident told the inspector that the owner-manager had told her when she first moved in you only have to ask, and that is exactly how it has been: whatever she has asked for has been provided promptly and unstintingly. This person said that the staff are all very nice and they all come in with a friendly face. Residents felt that there is very little restriction on what they do: indeed, the only restriction described was regarding smoking areas. One person told the inspector that any grumbles or queries are quickly sorted out, and that staff respond to them positively. A copy of the complaints policy and the Residents Charter is on the back of each bedroom door. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 17 Most of the staff have now had formal abuse awareness training, and further training is planned in the very near future. There is evidently a high level of awareness among staff about residents rights, and a commitment to promoting these. Residents were confident that they could discuss any concerns with senior staff or the owner-manager. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality outcomes in this area are good. Residents benefit from a particularly attractive environment, which is well maintained and well-suited to their needs. Most practices promote health and safety, but the practice of having communal toiletries detracts from the otherwise individualised service. EVIDENCE: The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 19 There is a very pleasant lounge with French windows onto the garden. There is an additional seating area in the conservatory. The dining room looked welcoming, with tablecloths and fresh flowers. The inspector recommended that consideration is given to acquiring some dining chairs that can move across the floor more easily, as this may make it easier for some residents to sit up to the table as well as protecting the staff assisting them. Seven of the bedrooms are on the ground floor, and six of these have the French window onto the garden. The secluded garden is exceptionally attractive, with lawns, flower-beds and shady areas. Each bedroom has an en-suite toilet and three have en-suite baths. There is a communal toilet on the ground floor, close to the lounge and dining room. There are three communal bathrooms around the home, one of which has a walk-in bath with overhead shower and another of which has a whirlpool bath. Electric bath seats are installed. There is a digital safe in each bedroom so that residents can keep medication and personal belongings securely. The maintenance log book has been resumed, and staff enter any necessary repairs or adaptations in this. The record shows that most repairs are being done promptly. The external window frames were being repaired and repainted on the day of this inspection. New carpeting had been fitted in the corridors, and many areas had been redecorated, adding to the overall impression of an inviting and homely environment. It is planned to have impervious flooring fitted in the laundry soon, and the home is awaiting quotes at the moment. The care manager confirmed that all bedrooms have now been fitted with window restrictors. The home was cleaned to a high standard, and several residents confirmed that this is always the case. Cleaning staff were careful to keep secure the chemicals they use, but the inspector found some bath cleaning tablets in the wicker bathroom trolley that were marked as an irritant, harmful if swallowed, and could release a toxic gas if mixed with acids. These are potentially dangerous and must be kept in line with COSHH (Control Of Substances Hazardous to Health) regulations. Also in this bathroom trolley were a number of communal toiletries, including a pot of cream, a comb, roll-on antiperspirants, and a razor. Communal toiletries do not promote an individualized service and may be a source of cross-infection. Each person must have their own toiletries, clearly labelled with the owner’s name. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality outcomes in this area are good. Staffing practices promote residents safety and well-being. EVIDENCE: There are two care staff on duty every morning and two in the afternoons. A senior staff member is also on duty during office hours, and an activities assistant works in the afternoons. A cook is on duty each morning, supported by a domestic assistant. A cleaner also works each morning. The deputy has particular responsibility for administrative tasks. At night one waking staff member is on duty, supported by one person on sleeping-in duty. Staff training certificates are kept in files in the hallway, so that residents or visitors can see what training different groups of staff have undertaken. Eight staff had training in abuse awareness earlier this year, and all staff had training in medications handling. Ten staff have had first aid training in the past year, bringing the total number of staff with a current first aid certificate up to thirteen. Other training in the past year includes fire safety, understanding dementia, manual handling, and basic food hygiene. Further training arranged for the near future includes abuse awareness, basic food hygiene, and first aid. Two care staff hold NVQ2. The care manager and her deputy are both doing NVQ4, and the deputy is about to complete the Registered Managers Award. Staff responsible for cleaning had training on The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 21 COSHH (Control Of Substances Hazardous to Health) and knew where the safety data sheets on the chemicals they use are kept. A checklist has been in use for the past year when new staff are recruited, and this has helped to ensure that all pre-employment checks are satisfactorily completed. Where foreign staff have been employed, certified translations of their documentation are on file. All staff had Criminal Record Bureau checks. The inspector advised that PoVA First checks must be carried out before any new staff work in the home. Staff have basic induction training on their first day at work, then start on the Skills for Care induction training programme. It is planned that existing staff will also undergo this training in the future. Staff turnover has been quite high. The care manager has been exploring possible reasons for this and has been working to further improve the training opportunities, the extent of staff consultation, and the working atmosphere in the home. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality outcomes in this area are good. Residents benefit from a well-run home in which their interests are put first. EVIDENCE: Mr Jackson is joint proprietor of the home with his wife, and is the registered manager of the home. He has the City & Guilds 325-3 in advanced management for care, and has a Diploma in Management Studies. He is still involved with the home on a daily basis but has delegated many of the management tasks to the care manager. She has NVQ2 and is currently doing NVQ4. Newer residents said that it is the staff who helped them to feel settled and comfortable so quickly. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 23 Staff described a very happy and supportive work environment. Seniors are seen as approachable, and any necessary equipment is promptly provided and well maintained. Staff meetings are being held every month, and a copy of the minutes is kept in the office. Staff meetings are also used as a mini training sessions on a variety of relevant topics. The home has given out its own questionnaires to some of the residents and relatives, and plans to draw up a development programme based on peoples comments, once these forms are returned. The care manager is also designing a survey for health care professionals and other visitors. The questionnaires that have been returned so far show that people feel they have had good involvement with care planning, that the environment is safe and pleasant, and that the staff team is very approachable. A contractor has been asked to visit to look at the homes TV reception, in response to comments on some of these questionnaires. The care manager plans to send out questionnaires twice a year. A copy of the most recent inspection report is kept in the hall. One persons cash is held by the home for safekeeping, but this was in the broken digital safe so it was not possible to check the cash amount. However, cash records include two signatures, a note of the balance after each transaction, and receipts for any expenditure made on the residents behalf. A format has been drawn up for use in staff supervision, which prompts discussion about how each staff member is carrying out their job, the support they are receiving, and their development needs. This record also includes a list of issues to be carried forward to the next meeting and the actions that need to be done in the meantime. Each resident has a copy of their individual fire procedure on the back of their bedroom door. These procedures have been tailored to each persons individual circumstances, taking account of issues like how mobile the person is and whether they have a pet in their room. Key workers go through these periodically with the person. Many of the fire doors are fitted with safe hold-open devices. The fire log book shows that fire precaution equipment is very regularly tested. However, the homes Fire Risk Assessment is very basic, and makes no mention of issues such as the potential hazards from laundry equipment or the type and frequency of training staff should have. The inspector recommended that professional help is sought in drawing up a Fire Risk Assessment that will ensure the home complies with the new fire regulations. The training record shows that some of the night staff have not had fire training for six months. Staff covering night-time duties must have fire instruction at least every three months. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 24 Hot water temperatures are checked on a weekly basis, and the temperatures of all baths or showers taken by residents are also recorded. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 3 11 3 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 3 3 4 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 26 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. 3. Standard OP9 OP9 OP26 Regulation 17 13 13 Requirement An accurate record must be maintained of all medications. Controlled drugs must be properly stored. All hazardous substances must be kept securely. Toiletries and personal care items such as creams and razors must not be used communally. Staff covering night-time duties must have fire instruction at least every three months. Timescale for action 23/10/06 23/11/06 23/11/06 4. OP38 23 07/11/06 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 OP22 Good Practice Recommendations Consideration should be given to acquiring some dining chairs that can move across the floor more easily, as this may make it easier for some residents to sit up to the DS0000008065.V312623.R01.S.doc Version 5.2 Page 27 The Old Vicarage 2. OP38 table as well as protecting the staff assisting them. professional help is sought in drawing up a Fire Risk Assessment that will ensure the home complies with the new fire regulations. The Old Vicarage DS0000008065.V312623.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street 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. 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