Inspection on 18/04/07 for The Old Vicarage Nursing and Residential Care Centre

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Nursing and... 25/10/05

The Old Vicarage Nursing and... 24/06/05

The Old Vicarage Nursing and... 18/01/05

The Old Vicarage Nursing and... 03/08/04

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Keer Sands Residential Home

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Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Old Vicarage Nursing and Residential Care Centre The Old Vicarage Fir Tree Lane Burtonwood Warrington Cheshire WA5 4NN Lead Inspector Anthony Cliffe Unannounced Inspection 08:30 18 and 19th April 2007 th 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 Nursing and Residential Care Centre DS0000034659.V328289.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 Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Nursing and Residential Care Centre The Old Vicarage Fir Tree Lane Burtonwood Warrington Cheshire WA5 4NN 01925 229944 01925 229944 Address 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) Cheshire Lifecare Ltd Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users to include: * No more than three service users aged 55 to 64 years of age may be accommodated. Date of last inspection 25th October 2005 Brief Description of the Service: The Old Vicarage is a 35-bedded care home providing personal care with nursing. It was originally a Victorian residence, which has been converted and extended. Accommodation consists of 3 double bedrooms and 29 single bedrooms, 11 with en-suite facilities. There were 5 lounges, a dining room, a passenger lift and stair lift and special bathing facilities. The home has a large garden with patio area. The home is situated on the edge of Burtonwood village within easy access from the M62 and M6. There is a bus stop outside the home for buses to Warrington, St. Helens and Earlestown. Weekly fees range from £350 to £450 per week The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on the 18th and 19th April 2007 and lasted twelve hours. A Regulatory Inspector carried out the visit. This visit was just one part of the inspection. Other information received was also looked at. Before the visit the owner was also asked to complete a questionnaire to provide up to date information about services provided. Questionnaires were provided for residents, families, and health and social care professionals to find out their views. During the visit various records and the premises were looked at. A number of residents, visitors and staff were also spoken with and they gave their views about the service. What the service does well: The Old Vicarage provides a welcoming, homely environment and is well maintained both internally and externally. Visitors are made welcome and their views on the Old Vicarage were positive. Residents’ health needs are well met by relevant documents on their needs being completed and liaison with health professionals. Residents are supported to have choice and control over their lives and there are regular activities taking place. The activities coordinator is enthusiastic to increase the range of activities provided to both individual and groups of residents. Residents receive a good variety and choice of meals and residents said meals were of a high standard. Staff are friendly, courteous and approachable and there is a stable staff team with no agency staff used. Care is of a good standard and residents’ and a visitors comments support this. Competent people who contribute to the management and are committed to improving the standards of services and facilities provided own the service. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.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 Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for residents and their representatives so they can make a choice about where they live. Residents’ needs are assessed prior to moving in so appropriate care can be provided to them. EVIDENCE: The Old Vicarage accommodates mainly people from the Burtonwood area and is welcoming to anyone from outside the area or with a disability, different ethnic or cultural needs or sexual orientation. Residents or their relatives were provided with a copy of the service users’ guide and statement of purpose on request and copies of this and the most recent inspection report were given out together. Service user guides were not routinely put in each bedroom. This contained details of the facilities and services provided to residents. Information could be provided in different formats on request to the owners. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 9 Eleven residents’ surveys were returned prior to the site visit. Nine of these recorded that residents or their relatives received information on The Old Rectory before choosing to live there. Two files were examined of residents who moved into The Old Vicarage. The residents had met with a registered nurse to discuss their care prior to moving in. Information was gathered and this was recorded. This included information on their physical and mental health. Copies of these documents were on residents’ files. Copies of social workers assessments and care plans were on file with information from where the residents were staying. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Completed records of care, liaison with health and social care professionals and good medicine management ensures residents’ health and welfare needs are met. EVIDENCE: The care files of two residents were examined. Each care plan had a pre admission assessment and an assessment by the social worker or nurse assessor. From looking at care plans, observing staff working practices and talking with residents, staff and visitors residents’ needs were met. There were good examples of care plans in place that monitored residents’ health. Care plans were individualised to each resident. The plans related to medical conditions and gave guidance to staff. There were regular contacts with other healthcare professionals recorded such as General Practitioner (GP), continence advisor and dietician. Residents’ records also contained monitoring forms for eating and drinking, risk of developing pressure ulcers and assistance with personal care. Good practice in routinely monitoring residents physical The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 11 health were in place and residents’ blood pressure and weight were monitored. Improvements in the physical and mental health of residents were recorded. Information in these was mainly reviewed monthly and demonstrated improvements in health. A resident had limited mobility on moving into the home but with encouragement from staff had started to use a walking aid and become more mobile. Another resident was assisted to eat through a tube. The dietician regularly saw him and recorded his weight was stable and staff provided information on which she made recommendations for his care. This information was generally transferred into care plan reviews but some information was not. The new manager and owner put this down to individual staff not reviewing some care plans. The new manager had audited care plans and had found some errors. Examples of this were one care plan was not reviewed for three months and reviews of care plans were not outcome focused and recorded ‘continue as plan’. Individual supervisions with staff had been arranged to discuss the findings. No concerns about the care of residents were identified. Eight out of the ten residents’ surveys returned prior to the site visit recorded that residents always received the medical care they needed. A relative/carer survey returned prior to the site visit recorded, ‘there is a genuine empathy with residents which is not put on for the benefit of visitors. Mum has felt wanted, safe and happy as possible’. A relative said, “I can honestly say this place is the best. My brother has been here for two years. He needed nursing care and had to be moved form another home. We chose here and it was the right choice. I can’t say anything else”. Another relative said, “Mum’s health has recently been through the mill. Because the staff here genuinely care about people they made sure she had access to the right medical attention like everyone else. It was not a case of oh well it’s her age. Staff are on the ball. The new manager at the first signs of her suspecting something had her tested and she had an infection. She contacted her GP and it was nipped in the bud. Now she’s fine”. Medicines management and administration was examined. No errors were noted on medicine administration records. A monitored dosage system was used throughout the care home. Stocks of medicines were replaced monthly. Receipts of supplied medicines were recorded. Where medicines were supplied in original packages and not supplied each month the stocks of these were transferred from one month to the next so staff knew when to reorder medicines. Records were maintained for the destruction of medicines. As recommended at the previous site visit the owner had introduced a monthly audit of medicines to look at the practice of medicine management and administration. Audits had been completed monthly. The new manager had introduced a more detailed audit which if errors where found identified who was responsible for rectifying errors the timescale for completion. This had not been used. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in maintaining their independence and making choices about their lifestyle so they have control over their lives. EVIDENCE: The Old Vicarage employs an activities organiser for fifteen hours a week. Details of the activities available were displayed in the home. Residents said there were a variety of activities available to them. Social activity care plans were in place and life histories completed by residents or their families. The activities organiser was present and demonstrated how she planned activities and was increasing information held on residents’ social preferences. She had a good understanding of residents and knowledge of them as individuals. She spoke about a resident who was cared for in bed due to his medical needs and said, “ I do hand reflexology and massage with him. I put on his favourite music and a lava lamp. His eyes flicker and he moves his head. He also makes sounds when sport programmes are on so we make sure staff put this on for him at weekends. I have one to one sessions with him at least three hours a week”. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 13 She demonstrated that for a resident who did not originate from the United Kingdom that she had researched his country of origin and found out information on its language, religion and population. She said, “He has told me about his, experiences and family. He can make himself understood and will call for help or say no if he doesn’t want something. I will put this information into his life history, which I am doing on everyone”. Social activities and preferences details were recorded. The details of daily activities were displayed on a white dry wipe board, which were changed daily. The organiser demonstrated that she had produced draft weekly programmes. She had completed a certificate in chair-based exercise and was to develop exercises around this. The local Primary Care Trust (PCT) also was loaning her materials to use in an exercise programme. She said that at weekends she worked as a care assistant and there were always activities going on. There were details of entertainers that regularly visited the home. At the time of the site visit the residents were involved in floor skittles and watching a weekly film of their choice. A resident said of his choices and daily routine, “It’s lovely here first class food and great staff. I didn’t like the other care home I was in and am only here until I move to the south. Here it’s different you can choose what you want to eat. Staff ask you what you want. Staff spend time with you and talk to you. I like to spend most of my time in the smoking room. I like my own company and the people who are in there are sociable. There’s always plenty to do. I enjoy reading and listening to music. If I don’t want to join in anything they leave me alone. Staff are respectful and leave to myself when I want. I know I won’t be here for long but I’d be happy to stay if I had to”. Another resident said, “I’ve been here for six years, it’s always been great. I still go out to town three days a week shopping. I enjoy the activities and she’s going to play dominoes with me soon. I get daily newspapers and weekly magazines. The food is first class, plenty of choice and freshly cooked, you can’t fault it. We have been provided with a separate room to smoke in. At first I thought I was loosing out, but understand the law is changing and you can’t even smoke in most places in town now. When I thought about it, it’s to my benefit as I can still smoke in the building”. Residents and relatives were very complimentary about the standard of food provided. A resident said, “I’ve only been here a short while but can say it’s a very good place to live. The food is so good, I really enjoy it. I have put weight on I enjoy it so much, plenty of choice. The food is freshly cooked no frozen stuff”. Eleven residents’ surveys were returned prior to the site visit and ten of these said residents always enjoyed their meals. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are acted on to demonstrate they are taken seriously. An informed staff group and manager protect residents from abuse. EVIDENCE: There were two recorded complaints since the last site visit. The owner and local council had investigated these. The CSCI had been contacted by the complainants and the owner and local council asked to investigate them. There were detailed records demonstrating a full investigation of the concerns raised. The complainants were involved throughout the complaint. The owner responded to a complainant to their satisfaction and was able to demonstrate this. Relative/carer surveys said of the complaints procedure, ‘they listen to any comments and act upon them. They are very friendly and approachable. I am happy with the care given to my relative and would recommend this home to anyone’. ‘The staff are very friendly and happy. If there are any problems you can talk to any of the staff or management and you know it will be sorted out. You feel as though you get a lot of support’. ‘Complaints procedure clearly posted, with an explanation on how to use it’. Eleven residents surveys were received and ten recorded that they knew how to make a complaint or who to talk to if they were unhappy. A resident said about complaints, “You haven’t asked me about complaints. I have none, but can talk to the owners or staff”. Another resident said, “I like everything it’s so well run. I listen to the other people who live here and they all say the same. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 15 You might find the odd one who has a grumble but you ask the majority of people who live here and they will agree it’s a nice place to live, very good. Can’t say any other words to describe it”. The owner was responsible for adult protection training within the home. She completed Action on Elder Abuse training in 2003 and arranged to complete the local council ‘Train the Trainer’ adult protection training in July 2007. All staff had completed adult protection training updates in February and March 2007. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and well-maintained environment, which is equipped to meet their needs. EVIDENCE: The Old Vicarage is set in its own grounds and has its own enclosed garden. The grounds were very well maintained and pleasant areas had been provided for residents to sit and walk in. The building continued to be maintained to a high standard. The owner had produced an improvement plan for the redecoration of the building and replacement of furniture and flooring. This included the refurbishment of a small lounge to an enclosed smoking room, redecoration of bedrooms, stairwells, replacement of the conservatory floor, purchasing of new furniture, curtains and bedding for bedrooms. The manager and owner confirmed that they were going to improve the signage on residents’ bedroom doors as bedroom doors only contained a bedroom number or the occupants’ name. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 17 Residents and relative/carers surveys recorded that the building was always clean and hygienic. A relative said they chose the Old Vicarage ahead of other care homes because of the atmosphere as being ‘friendly and non clinical’. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate to meet residents’ needs. Staff recruitment ensures that residents are protected. The induction and training programme provides a skilled workforce that protects residents’ welfare. EVIDENCE: Staffing levels were appropriate and the new manager and owner confirmed that staffing numbers were determined by the dependency of residents and could change. The home had an appropriate mix of qualified and unqualified staff. The recently appointed manager was experienced in the care of elderly residents. The pre inspection questionnaire returned prior to the site visit recorded that eighteen of the twenty-one care staff employed had an NVQ level 2 qualification. Staff interviewed said they had completed their NVQ level 2 and some were doing NVQ level 3. A staff member said, “It’s taken me two years to complete my NVQ level 2. I’ve had problems with it on and off but with the support of everyone I’ve finally done it”. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 19 Four staff had commenced employment and had been supervised through an induction programme, which included training on the protection of vulnerable adults. The records of these staff were examined. All contained appropriate identification documentation and completed POVA First and Criminal Record Bureau disclosures. All files had two written references. Files contained copies of the induction programme. The personal identification numbers of registered nurses were checked with the Nursing and Midwifery Council. Staff completed the induction programme supervised by the owner, manager or trained staff member. Induction programmes were based on Skills for Care induction standards. Staff files contained details of the training and supervision staff had completed. The owner said the application form was to be amended so a more detailed chronology of employment could be recorded. Staff had been provided with and had completed a variety of training. This included: wound management, health and safety, infection control, end of life care, food hygiene, adult protection and NVQ level 2 training as examples. Staff could access training on equality and diversity through the local council and the owner said all staff would be put forward to complete this training. A training record system had not been developed to recorded all mandatory training planned and completed and the owner clarified this would be developed in the near future in conjunction with the manager. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Consistent management and quality assurance systems, financial procedures and maintenance of the building and equipment safeguards residents and ensure they are safe. EVIDENCE: Since the resignation of the previous manager in November 2006 the owner had continued to work at the Old Vicarage daily when necessary with an experienced registered nurse managing and coordinating the registered nurses and care assistants. The owner had maintained responsibility for the management of the kitchen, domestic and laundry staff. CSCI had been informed of the management arrangements in place until the appointment of a manager. The owner had taken time to appoint an experienced registered nurse with management experience. The new manager had only been in post a The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 21 few weeks and had completed an application form to register as manager and the owner confirmed this was to be submitted. The owner said, “ We don’t rest on our laurels, we have to improve all the time. Since the last manager left we acknowledged some things on the clinical side of record keeping were not done, as some care plans were not reviewed. But there has been no negative impact upon residents and nobody has raised any concerns about the care of residents”. The new manager said since she came into post she had found staff “Knowledgeable and they know their roles and responsibilities. Having worked for a large corporate provider of care I have found the standards of care excellent and the support from the owner is excellent”. Residents said the home was efficiently managed and they could make comments on how it was managed. Since coming into post the new manager had contributed to the quality assurance system by auditing care plans and medicine administration records, identifying errors and revising the document to audit medicine administration and management. A care plans audit had been completed and matters arising form this was to be discussed with individuals as part of their supervision. The owner completed annual reviews of the policies and procedures within the home. An example of this was the medicines policy had been amended to include changes in the law on disposal of medicines. The owner had obtained a copy of CSCI guidance on meals and menu planning ‘Highlight of the Day’ which she clarified was to be discussed with the cook when menus were revised. The owner had revised how information was gathered from residents and relatives on their views about the standards of care and the services offered at The Old Vicarage and had completed a quality assurance survey produced in January 2007 based on the previous year. Residents’ responses were rates as very satisfied, satisfied or dissatisfied. Residents were between 96 and 99 satisfied with the environment, hospitality services, care provided, social care, and freedom of choice, privacy and dignity. Care provided and freedom of choice, privacy and dignity scored a high percentage of satisfaction. Comments were recorded in each outcome section were both positive and negative responses were made. An action plan was identified in each area to make improvements. The survey included information gained from relatives/visitors. The information gained showed a high percentage overall in the very satisfied score. Where areas for improvement were identified these were highlighted in the action plan. Areas for improvement that had been completed included a review of the menu in February 2007 and decoration of areas of the building, which commenced April 2007. There were rigorous monthly audits completed by the owner and manager that covered care of residents, accidents, pressure ulcers and treatments, the building including; kitchen, laundry and standard of cleanliness, care plans and notifiable incidents. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 22 There were residents/relatives meetings held at least twice a year. Heads of department and staff meetings were held at least six monthly and included catering and housekeeping. The owner said the frequency of staff meetings had not been as frequent due to the manager’s post being vacant and assured the frequency would increase. No personal monies other than personal allowances were held on behalf of residents. Relatives were billed directly for additional services such as chiropody or hairdressing. Residents’ personal allowances were safely secured and records for credits and debits maintained. Information provided by the provider in a pre inspection questionnaire and records held on site were examined. All the required maintenance and health and safety checks of the building and equipment had been completed. The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X X X 3 The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should be revised monthly and incorporate all advice from other professionals involved in their care. Care plans reviews should reflect if the care plan meets residents’ needs and not use terms such as ‘continue as planned’. The outcomes from the auditing of care plans and medicine administration records should clearly specify timescales for the maters identified to be addressed and form part of the ongoing development and supervision of staff. 2. OP7 The Old Vicarage Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Nursing and Residential Care Centre DS0000034659.V328289.R01.S.doc Version 5.2 Page 26 - 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!