Inspection on 18/07/08 for The Old Vicarage, Easton

This inspection was carried out on 18th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Vicarage, Easton 10/07/09

The Old Vicarage, Easton 12/07/07

The Old Vicarage, Easton 28/12/06

The Old Vicarage, Easton 29/01/06

The Old Vicarage, Easton 18/03/05

The Old Vicarage, Easton 25/10/04

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 09/11/2008.

CARE HOME ADULTS 18-65 The Old Vicarage 8 All Hallows Road Easton Bristol BS5 0HH Lead Inspector Sarah Webb Unannounced Inspection 18th July 2008 09:00 The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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 DS0000020336.V364933.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 Adults 18-65. 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 DS0000020336.V364933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address 8 All Hallows Road Easton Bristol BS5 0HH 0117 9399910 0117 9399910 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) www.brandontrust.org The Brandon Trust Ms Carol Tooze Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (1) of places The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 9 Adults with Learning Difficulties aged 18 - 64 years Staffing Notice dated 01/06/1999 applies Manager must be a RN on parts 5 or 14 of the NMC register May accommodate one named person over 65 years old. Will revert when named person leaves. 12th July 2007 Date of last inspection Brief Description of the Service: The Old Vicarage is a large building converted for 9 people with learning difficulties to live in. It has recently downsized to provide a service to 7 people. Currently the home provides nursing care but with a social focus. However, Brandon Trust are looking at changing the registration of the home from nursing to registered care. The home is in Easton, Bristol and near to local amenities. There are recreational facilities, shops and services near to the home. There are two large communal areas and 9 single bedrooms in the home. The home is in the process of converting one of the extra bedrooms into a second lounge. The home is surrounded by garden, has its own off-road parking and is situated in a quiet road near to a cycle path. Brandon Trust has a mission statement that includes ‘supporting and enabling people to live the lives they choose’ and ‘to empower the users of our service to determine their futures and enable them to reach their goals.’ Fees payable range from £1157.00 to £1191.00 per week. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out over one day. Before the visit, we looked at information received since the last inspection. During the inspection, we case tracked the care and support people using the service receive by looking at various records and documents. These included assessments, care plans, how people are supported in taking risks safely and how they are given their medication. We also looked at staff training records. We were shown around the house and spoke with people, staff, and the manager. A completed Annual Quality Assurance Assessment was received after the inspection. Some of the information provided has been included in this report. Four surveys were received from people using the service, three from families, a health care professional and two from staff. All of the surveys have been analysed and form part of this report. The requirements and recommendations have been met from the previous inspection. Two requirements and four recommendations have been made through this visit. What the service does well: People have a good relationship with staff. Staff support their complex needs well and encourage them to be independent and make decisions about their lifestyle. There is an ‘open’ atmosphere in the home and people can be confident that they will be listened to. The home has good links with local health and social care professionals and responds to advice given. Comments made by families included ‘I would like to thank everyone involved with the welfare and care of our relative. That it gives us a feeling of appreciation and peaceful mind to know they are in a home with staff who look after them so well’ The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 6 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 summary of this inspection report can be made available in other formats on request. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 Quality in this outcome area is good. People who want to use the service are given information to help choose a home that will meet their needs. Peoples’ needs are assessed before moving to the home to help ensure they can be met. Up-to-date contracts help to show people what to expect from the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a requirement has been met for both the Statement of Purpose and Service User Guide to be reviewed. The new manager has developed both documents that now reflect the needs of people living at the home, current practices and services in the home. A Service User Guide is in an easy read format to help people understand what the home has to offer. There are currently 7 people living at the home with one vacancy. Peoples’ needs are assessed before moving to the home to make sure the home can meet them. Most of the people choose to move together as a group many years ago. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 9 The manager said there had been several referrals made to the home to fill the vacancy but they have not been suitable. She said the vacancy will be filled by someone who fits in with the current group. Some people told us through surveys that they were asked if they wanted to move to the home. One person said they had been given enough information about the home while another said they had not. Some people did not respond. One person told us ‘I like living here as I like the people who live and work here.’ Staff had a good understanding of peoples needs and gave examples of how they are met. Since the last inspection a person’s placement has broken down and they have had to leave. It was evident that staff could not meet their needs and they were having an impact on the other people living at the home. We were told by all three surveys received from families that the home ‘always’ meets the needs of their relative. Care files showed that people are given a statement of terms and conditions for their stay. This includes service charges. They are told every year if there is a change. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7. 8, & 9 Quality in this outcome area is adequate. Care plans show how people want to be supported with their needs. Some areas need more detail when supporting people with their communication. Peoples’ care is not being reviewed by the home on a regular basis. People are involved in making decisions about their lives and in the planning of their care they receive. Risk assessments support people to take risks as part of their lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People’s care files included personal details, daily records, support plans, and risk taking. A requirement for care plans to be updated with peoples current support needs has generally been met. Some care plans showed the home has improved in recording peoples preferences and lifestyles. The information in these clearly showed how staff should be supporting people with their needs. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 11 However the manager was advised to include more information in another care plan about how an individual communicates and how staff should respond. A family told us that ‘the home understands the needs of people well’ and ‘really understands and knows my relative’. The home has encouraged people to make choices about how they want to be involved in the planning of their care. Person Centred Plan meetings are being arranged with a facilitator from outside of the home to help people understand their care. The manager is aware that people would benefit from more accessible information such as pictures and photographs to help them understand their lifestyle and their needs. Care files showed peoples care had been reviewed recently by their social worker. This was also confirmed by people using the service.. The Trust has procedures in place for peoples care to be reviewed monthly by the home. However there was sporadic information showing this. Some care files had no previous or current monthly reviews. Both the manager and deputy were unable to find this information and the manager said information was missing. People told us through surveys that they ‘always’ make decisions about what they want to do each day while another person said they ‘sometimes’ can. People have told staff that they do not like to have house meetings as a group. People can talk to their keyworker during planned 1:1 time. The manager said this has been more useful than the group meetings as people feel more comfortable in a 1:1 situation. Brandon Trust organise ‘forums’ for people so that they can be asked what they want and have a say in their service. Since the last inspection risk assessments have improved showing how people are being supported to take risks safely. These included how people are supported with their personal care, in accessing the community and travelling independently. The manager is aware of the depravation of liberty safeguards that will start in 2009 and has started looking at restrictions in place that may deprive people of their liberty. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good. The majority of people benefit from taking part in educational, social, and recreational activities. Although there have been restrictions due to staffing levels and transport issues, these are now being resolved. People are helped to keep in contact with family and friends if wanted. People are supported in making choices about their lifestyle and are helped to take responsibility in their daily lives. People benefit from a varied menu, and are able to choose the food they prefer and like. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The majority of the people using the service take part in meaningful activities during the week. These include farm and college placements, and work. This was seen through activities recorded on their care record and activity sheets. We were told ‘I really like the farm I go to’ The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 13 People access the community for different activities such as going to pubs, bowling, and day trips. However staff feel there are times when there are not enough staff on duty for activities to take place. A comment from a family showed they are ‘disappointed’ that a lot of daily projects have been ‘axed’ as their relative ‘enjoyed them and always talked about their visits’. Staff confirmed that not all people have day service hours to support people in the community. However the home has recently received twenty hours of day care support a week and this will be taken up by an individual who has no day care currently. The AQAA also showed the home needs to improve in increasing day activities and leisure opportunities on an 1:1 basis. A recommendation is in the process of being met for a vehicle to be provided in supporting people with activities. The Trust has agreed to buy a vehicle to help transport people to different activities. People confirmed they have had a holiday this year with a second one being planned. They told us they ‘really like going on holiday to different places.’ It is evident that the home has good relationships with peoples’ families. We were told through surveys received from families that the home ‘always’ helps to keep relatives in touch with them. A comment from family said ‘ An open door policy I can pop in to see my relative and phone anytime to make enquiries.’ People are involved in the daily routines of the home, and are encouraged to make snacks and drinks independently. People are offered a varied choice of food. Menus showed that peoples’ cultural background is respected and reflected individual choice. We were told ‘I like the food I get.’ We were told by a family that ‘The staff make steps to ensure that the right food is made for my relative as they have specialist needs’ and that ‘the home is good at taking steps to meet diverse and ethnic needs.’ The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. People are supported in the way they want with their personal care. They benefit from healthcare needs being well met. People are treated in a respectful way by staff. Medication procedures do not keep people safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peoples care plans show how they want to be supported with their personal needs. It is evident staff have built good relationships with people using the service. Interactions seen showed staff treating people respectfully and that they had a good understanding of peoples needs. Two people told us through surveys that staff ‘always’ treat them well while another said ‘sometimes’ and that they didn’t always like it when staff tried to help them when they got ‘worked up.’ People are helped to use different healthcare services, including going to dentist, physiotherapists, opticians and chiropodist. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 15 Although people are supported in having an annual health check through their local surgery, the AQAA has told us that an area of improvement is for people to have an ‘OK’ Health check. This helps to assess and plan for their health needs. Staff showed they had a good awareness of recognising when people are unwell and unable to communicate their feelings. A health action plan would also help to support staff better with more detailed information about individuals specific health needs. The manager has also recognised that there are some areas that staff need specific training in. The home has good working relationships with healthcare specialists and professionals. Comments from a healthcare professional told us that ‘the service always asks for advice and acts on it to manage and improve individuals health.’ We were told by a family that the home ‘always’ gives the care and support to their relative. Since the last inspection the staff supported an individual through illness that resulted in their death. The Trust has policies and procedures for the administration, storage, recording and disposal of medication. Medication profiles had a photograph with the record to make sure people are given the right medication. Medication is kept safe in lockable cabinets in an office and is given by senior qualified staff. There are no controlled drugs kept on the premises. Records showed that medication is received monthly and is checked in by staff. This was seen recorded on medication administration records (MAR). A random selection of medication given was checked against the MAR. There has been one occasion when medication given has not been recorded and this puts people at risk of harm. The record of an ‘as required’ medication did not correspond with balances on stock control records. A requirement is made for a record to be kept of all medication administered so that people are supported safely. The home keeps a record of medicines disposed. Peoples’ medication is reviewed regularly. This was seen through correspondence from healthcare specialists. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. The people that live at the home feel confident to approach the staff with concerns. People can expect to be protected from abuse by trained staff. However staff would further benefit from being updated in safeguarding training to further ensure people are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home follows the organisation’s complaints policy and procedures. There is a complaints form for people to use in an easy read format to help them understand the process better. The complaints log showed that there has been one complaint since the last inspection. A requirement has been met for a record to be kept of the outcome of complaints. One person said they were ‘unsure’ about how to make a complaint, while two other people told us they knew what to do. People told us that they know who to speak to if they are not happy. Two people also said staff ‘always’ listen to them while another said ‘sometimes’. The manager said an area of improvement is to use advocates in supporting people with their views. Comments from two families stated they did not know how to complain and that they have never been in a position to complain. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 17 Another family said ‘ I have no concerns so far, this home is doing a good job and I have good communication with the staff.’ Staff had a good knowledge of safeguarding procedures and they receive training in understanding abuse through their initial induction. However not all staff have received updating in this area. A recommendation is made for staff to attend training in safeguarding to keep staff informed and updated with current practice. A requirement has been met for risk assessments to be carried out for people who may need support through physical intervention. A care file had a risk management plan showing staff how an individual is supported. This included their behaviour indicators, diffusion strategies and their physical intervention needs. However, the manager said that the home has not had to use any physical intervention for some time and that the use of this practice can be detrimental to peoples’ health and welfare. Staff continue to be updated in appropriate training if they are challenged. A requirement has been met for the home to provide suitable furniture for people if they become challenging and need to be supported through physical interventions. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, & 30. Quality in this outcome area is good. People live in clean, safe, and comfortable environment. There are some areas that are in the process of being maintained to ensure peoples health and safety is protected. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Old Vicarage is a listed property built over two floors. There are nine single rooms, a lounge, kitchen, dining room and various bathrooms. An attic is used for storage space. The home has two offices one on the ground floor that is used for daily recording and another on the first floor that holds other care files and is also a sleep in room. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 19 The home has been downsized to provide a service for seven people. One of the spare bedrooms is to be converted to another lounge area and to provide a quiet space. Three bedrooms have been redecorated and refurbished, meeting a requirement. A relative told us that the home has made their relatives bedroom ‘comfortable and homely.’ We also saw this room and saw the improvements. People are offered keys to their rooms, which the majority of people use. The home is in the process of linking the bedroom doors into the fire systems so that people are kept safe. There are special adaptations and equipment to support people with their independence and safety. The manager told us that the kitchen is locked at night so that people are kept safe. We advised that a risk assessment is carried out for this restriction and reviewed on a regular basis. ‘Waking’ staff on duty at night can help people to access the kitchen safely at night. The home is in the process of making improvements to the environment. Arrangements are being made for a bathroom to be refurbished as a ‘wet’ room and an en suite to be fitted to an individual’s bedroom. Bedroom windows on the first floor are to be double- glazed and the hallway and stairwell is to be decorated. The garden is being maintained and improved so there is additional space for people to use. These improvements will be followed up at the next inspection. A cleaner is employed 30 hours a week and people told us the home is ‘always’ fresh and clean while another said ‘sometimes.’ The home was clean on the day of this visit. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, & 35. Quality in this outcome area is good. People benefit from a staff team who have a good understanding of their role and responsibilities and who are trained to meet the individual needs of people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with showed that that they had a good understanding of the aims of the home, their role and responsibilities, and a good knowledge of peoples needs. Currently there are five qualified staff employed and with nine care staff. Since the last inspection three new staff have moved to the home while other staff have left. However there is still a core of staff that has worked for several years providing consistency for people. Regular bank staff are used so that people know who will be supporting them. Three staff are on both an early and afternoon shift and two staff on duty at night with one on a ‘waking’ duty. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 21 New staff complete an induction programme that includes the Learning Disability Award Framework and then are offered to register for National Vocational Qualification level two. A new member of staff confirmed this. There are currently three care staff that have a National Vocational Qualification. All staff spoken with said the team work well together and that there is good communication. Staff told us that the team are very ‘experienced’ and ‘have good knowledge of the people living at the home’. This was confirmed through discussion and observation. Training records confirmed staff are given relevant training to their role helping them to understand and meet the needs of people. Training offered included mental health, challenging behaviour, and communication. Staff confirmed that necessary checks were made before they started work at the home. Staff records are kept at the Trust’s headquarters and were not looked at during this visit. Some staffing records kept at the home had not been completed including staffs’ next of kin. Not all employee checklists had been completed. The checklist should include information about Criminal Records Bureau checks and references. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 22 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 Quality in this outcome area is good. The home now has a permanent manager who is competent to run the home and will hopefully ensure inprovements will continue including maintaining peoples records. Peoples views are sought in different ways and people are safe within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Old Vicarage has had several changes of managers in the past year but there is a permanent manager now in post. Ms Tooze is qualified, competent and experienced to run the home. She is a qualified nurse (RMA), and is a National Vocational Qualification assessor and internal verifyer. Since this visit she has been registered with us as the manager. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 23 It is evident that the home now needs a period of stability. The manager reflected that the past year has been a difficult one with an individual’s placement breaking down, illness resulting in death of another person who used the service and many staff changes. It was evident that over the past few months, some of the record keeping has not been maintained. Despite staff being aware of peoples needs, the records did not always reflect this. The majority of the paperwork and records are being transferred to the upstairs office. Ms Tooze is well aware of areas that need to be improved and has started address them. There have been no annual questionnaires sent out to people using the service this year asking them about the service they receive. People are helped to express their views through 1:1 meetings. The Trust also consults with people through quality monitoring processes. The staff team have set targets and goals including accessible care planning for people and more support through advocates. Annual Health and Safety audits and in house checks are carried out regularly helping to keep people safe. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x 2 3 x The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 25 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. 2. Standard YA6 YA20 Regulation 15(2)(b) 13(2) Requirement Keep peoples’ care plans under review. Keep a record of all medication given. Timescale for action 01/08/08 19/07/08 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. Refer to Standard YA19 YA6 YA35 YA40 Good Practice Recommendations Develop health action plans to help show how peoples healthcare is met. Investigate ways of involving people in the planning of their care through accessible formats. Update staff with training in safeguarding to help keep staff informed of current practice and to further ensure people are kept safe. Keep an up to date employee checklist at the home to show that staff have had necessary checks made before they are employed. The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Vicarage DS0000020336.V364933.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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