Inspection on 28/12/06 for The Old Vicarage, Easton

This inspection was carried out on 28th December 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 found no outstanding requirements from the previous inspection report, but made 5 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 18/07/08

The Old Vicarage, Easton 12/07/07

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 09/07/2008.

CARE HOME ADULTS 18-65 The Old Vicarage 8 All Hallows Road Easton Bristol BS5 0HH Lead Inspector Andrew Pollard Key Unannounced Inspection 28th December 2006 09:30 The Old Vicarage DS0000020336.V323707.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.V323707.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.V323707.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 Mrs Susanne Burch 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.V323707.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. 29th January 2006 Date of last inspection Brief Description of the Service: The Old Vicarage is a large building converted to house 9 residents with learning difficulties. There are two large communal areas and 9 single bedrooms in the home. The home is surrounded by garden, has its own offroad parking and situated in a quiet road near to a cycle path. The home is in Easton, Bristol and near to local amenities. There are recreational facilities, shops and services near to the home. The home provides nursing care but with a social focus. Fees payable are £1,077.62 per week. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used in the production of this report; observation, pre-inspection questionnaire, discussion with staff, resident surveys, relative comment cards, tour of the home and sampling policies, records and care documents. The inspector met several residents and staff. The registered manager, one registered nurse and two care assistants were interviewed about their roles and responsibilities, their training needs, and how they assist and support residents. The building is large and old and would not be suitable for people with physical disability or the frail elderly. Plans are in place to update the environment and reduce the registration by two creating a new quiet lounge and office. This report has been written using all available evidence including a visit to the home. What the service does well: What has improved since the last inspection? Two residents have been transferred to more suitable placements. All residents’ risk assessments and care plans have been reviewed and updated. The kitchen has been fully upgraded. There have been improvements in the bathrooms albeit one to a higher standard than the other. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 6 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.V323707.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.V323707.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): 1,2,5 Quality in this outcome area is good. Prospective residents would be given all relevant information in written or verbal form about the home. Full assessments of care are carried out and updated. Residents have written contract and term and conditions of residency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service users’ guide contained a range of detailed, helpful information about life in the Home and the service that is provided, including information about daily life. The documents include colour photographs of the Home to further show what type of service is provided. All residents are issued with a statement of terms and conditions for residency. They state the house rules and fees payable. Where able residents have signed contracts. There have been no new admissions since the last inspection. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 9 Two residents have transferred to other care settings, the process was managed through the multidisciplinary team and early indications are that they have been successful. Previous inspections found that residents’ assessments were based on ‘person centred planning’, meaning the views and wishes of residents are at the centre of all care provided. There was a range of detailed assessment information recorded about residents care needs. Residents are encouraged to be involved in the care planning process where they are able or willing. One relative takes some part in the process. Assessments had been reviewed and updated regularly demonstrating that staff monitors residents’ changing needs. The Old Vicarage DS0000020336.V323707.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 good. Care plans are well written and enable staff to provide a consistent and individualised care. Residents are involved with the personal care planning process The homes philosophy promotes resident’s individual development, selfdirection and empowerment. Residents are supported to take risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home operates a named nurse and “key working” system whereby each resident has a named nurse and support worker who play a more central role in co-ordinating the care they receive. This provides meaningful staff support to residents, which is particularly important to those who have complex needs. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 11 The staff have reviewed the format of the care plans, which provide detailed information and input from the individual residents about their wishes. The “Person Centred Planning” process is now well established in the home, which seeks to ensure that care is individualised and based on the involvement and participation of residents where possible. Three residents make use of photo boards and some have some signing skill, which aid communication. Each file contains personal information; individual support and health care needs, daily routines, care plans and risk assessments. The information seen was well written and provided evidence that the home provides a holistic service which takes into account social, mental health and physical care needs. The care plans contained information detailing how to support residents to meet their psychological, social and health needs and how to respond to the person if distressed or agitated. One resident has specific cultural needs, which were identified and accommodated as part of his care plan. Continuation records are made at each shift change and monthly summaries made for each element of the care plan. It was suggested that a certain number of records could be combined and held together to reduce the bulk of files. Risk assessments have been reviewed and are updated at least annually and relate to individual needs. Residents are encouraged to take risks as part of independent lifestyles. An OT is facilitating staff training to reaccess all residents in relation to their safety in the community and ability to manager shopping, use of buses and road safety. The Old Vicarage DS0000020336.V323707.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): 12,13,14,17 Quality in this outcome area is good. Residents have active life styles although some limitations are related to staffing levels at times. Residents are provided with a healthy, well balanced diet and staff work hard to support them to live as part of the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are supported to have active lifestyles. Each person has a weekly plan, which is tailored to his or her individual preferences and offers suggestions to staff to facilitate in accord to the residents wishes. These range from paid employment to attendance at college courses and drop-in centres or simple trips to shops, cafes or pubs. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 13 Staff work hard supporting residents in what is regarded as an essential role to support residents live a varied and fulfilling life. Currently all residents require escort when going out. Some resident’s work at Elm Farm, splinters and cleaning, others attend art and drama classes. Day care workers also provided a limited number of hours per week. There was information written in daily records showing residents access community and leisure services. Residents are supported to maintain friendships and links with their family a number of whom take an interest in the home. Some residents go out with relatives or for home visits facilitated by staff. One person has particular cultural needs and staff incorporates his food choices recognition of festivals and facilitate his attendance at the “People first black association” The vicar from the neighbouring church makes occasional pastoral visits. There are no residents from other faith backgrounds. Two resident are members of the “Kandy” group. Some residents have established friendships outside of the home including people they have met at other homes or day placements. Each person is offered an annual holiday or day trips if preferred. The home has a minibus but it currently not in use and awaiting replacement, this delay is restricting resident activities at present. The majority of residents are able to make snacks and beverages with supervision. The menus offer choice for all meals and the residents select their choices the day before. A new style of picture book is being trialled to assist resident to have a wider choice of food combinations. One person is supported in eating a particular diet that reflects their cultural background. The staff seek to ensure the menus are nutritionally well balanced and varied, so that residents are provided with a balanced diet. Fridge and freezer temperatures are monitored. diet. The Old Vicarage DS0000020336.V323707.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): 18,19,20,21 Quality in this outcome area is adequate. The staff provide appropriate personal and nursing care in a sensitive manner to maintains residents dignity, health and well-being. Proper arrangements are in place for residents to access primary and secondary healthcare services. The management of PRN and drug disposals requires improvements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were observed assisting residents with their needs in a calm and sensitive manner and managed situations well if residents became agitated. Resident’s care plans included information, stating how residents wish to be supported to meet their physical, mental health needs. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 15 In the past the residents received at least quarterly visits from a consultant Psychiatrist team, however this is no longer being provided and has been replaced by an on-call service. All residents are registered with Dr Allen who has offered a basic service in the past, however due to the loss of regular Psychiatrist input the manager is considering requesting more regular visits from the GP. In a comment card the GP said he was satisfied with the overall care provided to residents and felt there was good communication with the home. All residents are given the opportunity to be seen by dentist and optician at least annually and where appropriate a chiropodist. The manager is considering the possible value of Reflexology for some residents and the creation of a multi-media room in the new lounge. There are policies and procedures for the administration, storage, and disposal of residents’ medication. Each resident has a medication profile and a photograph maintained with the drug records to ensure medication is dispensed safely. Up to date records were kept of medication received into the Home. There were no disposal records and the bin used to store drugs awaiting disposal was insecure meaning that its contents could easily be tampered with or removed. Several residents prescribed PRN medication did not have the frequency or maximum dosage in 24hours recorded on the chart. The medication administration charts were legible, up to date, and contained the signature of the dispensing nurse with the exception of one round where the chart was blank and the reasons for any omissions had also been recorded. The Old Vicarage DS0000020336.V323707.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. There are robust and comprehensive policies in place to manage complaints or allegations of abuse to safeguard residents. There are good arrangements in place for staff training and awareness of POVA matters so residents can expect to be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The trust has a comprehensive and robust complaints policy and procedure. There is a copy of the complaints policy is displayed on the notice board; the policy is written in plain language and is also contained in the service users guide, and a copy of which has been given to each resident. In general residents complaints would be raised verbally. Staffs considers it their role to advocate on behalf of residents. The one relative comment card indicated they had never had cause for complaint, but rather praised the staff for their care and compassion. The home has links with the People First advocacy service. There have been no complaints from residents or others concerning care in the home. One resident wished to complain about the quality of the downstairs bathroom (referred to in the next section). The staff met demonstrated a good understanding of their responsibilities around the principle of the protection of vulnerable adults. Staff also explained The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 17 in detail how the challenging needs of residents in the Home have a significant impact on the needs and safety of other residents. A resident recently discharged to a more suitable environment has significantly reduced the escalation of challenging behaviour in the home from other residents. This was confirmed by a reduction of incident and accident reports All staff have attended training courses related to the protection of vulnerable adults from abuse. The Home also has a `protection of vulnerable adults’ procedure and a range of guidance information, which is needed to help staff understand their responsibilities to protect vulnerable adults in their care. However a number of residents were still clearly at risk. The Old Vicarage DS0000020336.V323707.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): 24,25,27,28,30 Quality in this outcome area is adequate Overall the homes décor is beginning to look shabby so residents do not benefit from a homely and comfortable environment. The ground floor bathroom is adequately equipped but poorly decorated. The first floor bathroom is in a good state. Bedrooms show high levels of individualisation. Shared spaces are suitable for their purpose. The home is generally clean and tidy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home is a converted older property, built over two floors, which can be accessed by stairs only. The home comprises of nine single rooms a lounge, dining room, kitchen, laundry and bathrooms. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 19 The kitchen has recently been refitted to a high standard. Due to the recent discharge of two residents the registration is to be reduced to eight. One of the spare rooms is to be converted to a quiet lounge and the other to an office. Residents were observed sitting in communal areas looking comfortable in the environment. The creation of a first floor quiet lounge give residents more choice and will be helpful in the reduction of challenging incidents by allowing residents more space and will make it easier for staff to manage these incidents. The majority of bedrooms and all the communal areas were viewed. Bedrooms are all for single occupancy, and were mostly adequately decorated and maintained. However a number of rooms will soon need re-decoration, as they appear tired. Bedrooms do not have en suite facilities; however there are bathrooms and toilets located within close proximity, and a washbasin in each bedroom. All rooms show evidence of personalisation and all residents have a key to their rooms. There is a spacious dining room situated on the ground floor and a large table in the kitchen. There is one resident who chooses to smoke. The smoking policy has been reviewed to take into account the wishes and needs of the whole resident group. There are adequate toileting and bathing facilities available to residents and where necessary the appropriate equipment has been supplied. Facilities were clean when viewed. The ground floor bathroom was in a very poor condition and needed urgent improvements. A new bath has been installed and the fan replaced, however the general appearance of the bathroom is poor and it looks shabby. The upstairs bathroom has been upgraded and decorated to a good standard. The carpets in the hallway and stairs have been cleaned but remain badly marked and stained. A requirement for replacement or an alternative floor covering to be installed by 10th of January 07 was made at a random inspection in August but to date has not been met. Overall the general standard of cleaning was good. The Old Vicarage DS0000020336.V323707.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): 32,33,35,36 Quality in this outcome area is good. The home is adequately staffed with appropriately trained and experienced staff. Staff have the resources and skills to meet residents’ complex needs. The staff are well supervised. There is a robust recruitment procedure in place that protects vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing rotas indicated that there are generally sufficient numbers of staff on duty to meet the needs of residents and in general the requirements of the staffing notice which is a condition of registration and must be complied with. There is a minimum of four staff recorded as being on duty in the morning, and afternoon. At night there are one registered nurse and two care assistants on duty. The manager works two days ‘nine to five’ management hours, and three shifts each week. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 21 A copy of the staffing notice was given to the manager so that a proposal can be put forward for any amendments should the Trust formally reduce the registration of the home to seven beds. The manager considers it a priority to maintain staffing at sufficient levels to allow community access for the residents. There is currently a vacant housekeeper post for 8 hours per week. In discussion with all of the staff who were on duty, it is evident they had a good knowledge of their roles and responsibilities, and understood residents needs. Copies of job descriptions are within personal files and clearly stated what is expected. There is a reasonably low staff turnover in the home and the consistency of staff presence is important to the wellbeing of the residents and maintaining the strategies of care that prevent challenging incidents and tensions in the home. However one relative did comment on the number of staff changes. Bank and some agency staff have been used recently to cover gaps in the rota and at present vacancies have been frozen. The manager considers that the staff work well as a team and supported one another. At previous inspections it was considered that the Trust had a robust recruitment procedure in place that protects vulnerable adults. All personal files are now held on the premises, which included completed application forms, two references and criminal records checks. There was also evidence that pin numbers had been checked for the RN’s. No new staff had been recruited since the last inspection. All new staff completes a Trust induction programme including the Learning Disabilities Award Framework and progress to NVQ level 2 awards. The majority of staff have completed the level 2 award. All staff receive statutory training in first aid, fire, manual handling and food hygiene and protection of vulnerable adults. The manager has a schedule of those staff requiring updates. Staff continue to attend external courses and a varied prospectus of learning is offered by the Trust. There is a structured, regular system of one to one supervision sessions for all staff and an annual appraisal. The Old Vicarage DS0000020336.V323707.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, 39,42,43 Quality in this outcome area is good There are various methods and systems in place to obtain residents views. Residents’ benefit from a well run home. There are appropriate arrangements in place to service and repair plant and equipment. The home has good Health and Safety arrangements. This judgement has been made using available evidence including a visit to this service. . The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 23 EVIDENCE: Ms Burch has completed the level 4 managers award. Residents said they liked Ms Burch and staff consulted with spoke positively about her. She has been working at the home for a number of years and has demonstrated an ability to change working practices during this time. Ms Burch displayed a good knowledge of her responsibilities as a registered manager and works positively to meet requirements and recommendations where she has the power to do so. The staff spoken with displayed a clear awareness of their roles and responsibilities. There are monthly residents meetings, which are well attended, and resident participation is encouraged and quality monitoring takes place by consulting with the residents. There are monthly staff meetings and RN meetings of which records are kept. Mr Massey carries out visits to the home for one to one supervision with the manager and writes Regulation 26 reports. There are recently reviewed health and safety procedures in place for staff and residents. Annual Health and Safety Audits are carried out by the Trust and monthly inhouse checks carried out. Particular attention is paid to COSHH issues and access to cutlery. Positive intervention training updates are annual but the manager hopes to arrange a whole team update in future rather than individual updates. All residents have individual risk assessments, which are regularly reviewed. The gas safety certificate was up to date and in order. The electrical installation safety certificate was not available. Portable appliances had been checked annually. The fire alarm system had been inspected and all required tests and drills have taken place. Fire safety training is updated annually. The Old Vicarage DS0000020336.V323707.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 X 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 2 25 3 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 X 33 2 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 X 3 X X 2 3 The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 25 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 YA27 Regulation 23.2 (b) Requirement Refurbish the ground floor bathroom. Timescale for action 05/04/07 2. YA24 23.2. (b) Replace the carpet in the hallway 10/01/07 or use an alternative floor covering. Arrange for a periodic electrical installation safety inspection to take place if there is no current certificate in place. All aspect of the staffing notice and conditions of registration must be met in full. Devise a secure method to store drugs awaiting disposal and make records of such. 28/02/07 3. YA42 23.2 (b) 4. 5. YA33 YA20 18.1 (a) 13 .2 01/02/07 01/02/07 . The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA19 YA20 YA13 Good Practice Recommendations Introduction of the “OK Health Check” to help develop health action plans. Ensure bottles of “As required” medication state actual direction for use and the maximum dosage to be given in 24 hours. Make arrangements for rapid replacement of the mini-bus. The Old Vicarage DS0000020336.V323707.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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.V323707.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!