Inspection on 26/07/06 for The Old Vicarage Nursing Home

This inspection was carried out on 26th July 2006.

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

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

Other inspections for this house

The Old Vicarage Nursing Home 20/08/07

The Old Vicarage Nursing Home 10/01/06

The Old Vicarage Nursing Home 21/08/05

The Old Vicarage Nursing Home 12/01/05

The Old Vicarage Nursing Home 08/07/04

The Old Vicarage Nursing Home 16/03/04

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 Home, 160 High Street Chasetown Nr Walsall WS7 8XG Lead Inspector Pam Grace Key Inspection 26 July 2006 14:15 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 Home, DS0000022358.V305418.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 Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Nursing Home, Address 160 High Street Chasetown Nr Walsall WS7 8XG 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) 01543 685588 01543 683306 Morecare Limited Care Home 27 Category(ies) of Dementia - over 65 years of age (27) registration, with number of places The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. DE Dementia over the age of 60 years for 27 persons Date of last inspection 10th January 2006 Brief Description of the Service: With its Victorian façade, thoroughly renovated and entirely private, The Old Vicarage Care home provides specialist nursing care for those service users suffering from the effects of dementia over the age of 60 years (27).The home is located on a main road in Chasetown with easy access for visitors, not far from a few shops. The main town is only two miles away. There is a medium sized garden with a sun patio and seating area. This is accessed via a ramp and suitable for wheelchairs. There are sufficient car parking facilities. The current fees range between £304.00 minimum - £500.00 maximum weekly. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken by one inspector, over a period of approximately 6 hours. The acting Care Manager Ms Jennifer Khadoo R.M.N. assisted the inspector throughout the inspection. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, and residents. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the manager, outlining the overall findings of the inspection, and the requirements made. Residents spoken with were very positive about the care they were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. What the service does well: The management and staff make the residents’ visitors and relatives welcome, and there are frequent visitors to the home. Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Residents and visitors spoken with were very positive about the care that they and their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. The acting Care Manager has been in post for approximately the past 3 months, she has a clear vision for where she wants to take the home, and is very positive in her approach, in order to achieve this. To this end she has been pro-active in making plans, which are in progress. The home was clean, warm and comfortable. The décor was well maintained. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Care plans should be signed by the resident, and or their relative, or representative. They should include information relating to arrangements to be made in the event of the resident having terminal illness. Residents’ social needs must also be identified and recorded, including preferences. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 7 Dining tables should have placemats and flowers to brighten the room. Some items of furniture in the home still need replacing, these include comfortable chairs in the lounge, small tables, and items of bedroom furniture. Staff training must include Fire, POVA and Dementia. The home must obtain a copy of the POVA policy/procedure. Individual training records for staff must be established, as well as a clear training schedule for the coming year. A quality assurance system must be established by the home to enable feedback from residents, relatives, representatives, health and other professionals. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence, and confirming current practice with the home’s administrator. Each resident is given a signed contract; following a full pre admission assessment to ensure their needs could be met in the home. Intermediate care is not provided by the home. EVIDENCE: The home’s Statement of Purpose is currently under review. Prospective residents are invited to look around the home prior to making a decision. Residents each have a signed contract/terms and conditions following a preadmission assessment. During discussion with the home’s administrator, it was acknowledged that all prospective residents, relatives, or their representatives receive verbal confirmation that the home can meet their needs, however, it would be considered good practice for the home to send written confirmation of this. The home does not provide intermediate care. The Old Vicarage Nursing Home, DS0000022358.V305418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is adequate. This judgement has been made using available evidence, general observation, and discussion with a relative. Care records seen evidenced that residents’ health and personal care needs are being met. However, care plans did not contain arrangements in the event of terminal illness, a social history, or details of residents’ preferences. EVIDENCE: A random sampling of 4 care plans was undertaken. Appropriate risk assessments were evident in care plans seen. Wound treatment records were clear and up to date, and were cross-referenced with daily records, and the daily diary. Visits by health professionals were well documented. Care records seen evidenced that residents’ health and personal care needs are being met. However, care plans seen were unsigned, and did not contain arrangements in the event of terminal illness, a social history, or details of residents’ preferences. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 11 Care plans must contain details of any specialist communications needs of the resident, and methods of communication that may be appropriate to the resident. They must also contain a record of any limitations agreed with the resident as to the resident’s freedom of choice, liberty of movement and power to make decisions. The acting Care Manager confirmed that in regard to care plans, the current Kardex system is being replaced with a clearer, more comprehensive system. However, this is still in the planning stage. Service users are protected by the home’s policies and procedures for dealing with medicines. Currently there are no residents who are able to self medicate. Staff demonstrated a personal empathy with residents through a respectful, yet friendly discourse. A visiting relative said he was pleased with the services and care his mother received, he said that there had been a good all round improvement in his mother’s health and quality of life since she had moved into the home. The Old Vicarage Nursing Home, DS0000022358.V305418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality in this outcome area is adequate. This judgement has been made using general observation, discussion with residents and staff, and examination of records. Menus are undergoing review, and are to be rotated on a four weekly basis. Visitors are made welcome, however, there is little evidence of activities/stimulus provided to residents. EVIDENCE: The current menu is rotated on a two weekly basis, however, this is under review, and it is intended that a four weekly menu be introduced in the very near future. The Inspector discussed the provision of soup and assorted sandwiches each day for tea, and asked if there could be more variety of food provided for residents at tea- time. Residents are offered snacks and drinks at regular intervals throughout the day, including cold drinks, tea and biscuits, and cake. A supply of fresh fruit and yoghurt is also available for this purpose. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 13 Meals are cooked in the main kitchen, in the sister home next door, and are then brought across by staff. The home’s kitchen was clean and tidy, and is used to make drinks and snacks for residents. The main kitchen was not inspected on this occasion. Staff held a friendly and sympathetic interaction with service users in lounge areas, and at teatime in helping those who required assistance. The menu for the day was displayed in the dining room, and the dining room décor is light and pleasant. However, tables in the dining room were bare and uninviting, there were no tablecloths and or place mats on tables. Staff spoken with confirmed that during meal times they would offer discreet assistance to those who required it, and that the choice of dining room, lounge or bedroom was at the discretion of service users. Although staff said when asked, that they know residents very well, activities at the home are not well recorded, and are mostly undertaken by staff on an ad hoc basis. Care plans do not contain a social history for residents. This makes it difficult for staff to ascertain preferences and choice for individual residents. Staff training records show that staff have not received appropriate training in Dementia care. Comment cards received from relatives were very complimentary of the service, they included remarks such as they were `very satisfied with all of their relative’s care’, `staff are exceptionally helpful’, and `we know our mum is in good hands’. The Old Vicarage Nursing Home, DS0000022358.V305418.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality in this outcome area is poor. This judgement has been made using discussion with staff, and examination of records. Service users and their families are able to express their concerns and/or complaints. Staff were aware of their right to express their grievances and of Whistle–blowing procedures. The home does not have a POVA policy and procedure in place. Staff training records show that POVA training has not been recently undertaken. However, the acting Care Manager and staff spoken with were aware of their responsibilities in regard to the protection of residents from abuse, of all natures. EVIDENCE: The home has a clear system of recording complaints. One complaint had been received by the home since the last inspection. This was appropriately dealt with by the acting Care Manager, and was well documented. The complaint was not upheld, and was amicably resolved. There were no requirements or recommendations made by the Commission for Social Care Inspection (CSCI) as a result of this complaint. A complaints book is maintained which shows a responsible approach in handling complaints appropriately. Staff when spoken with were aware of their right to express their grievances and of Whistle–blowing procedures. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 15 The acting Care Manager confirmed that the home does not have a POVA policy and procedure in place. Discussion took place as to how to obtain a copy. Staff training records showed that POVA training has not been recently undertaken. Staff, when spoken with, were aware of their responsibilities in regard to the protection of service users from abuse, of all natures, but could not recall when they had last attended POVA training. It is a requirement of this report that the home must obtain a POVA policy and procedure, and staff must receive appropriate Protection of Vulnerable Adults training. An Advocacy service is available to those who require it as indicated in the Statement of Purpose, although no one is formally represented at this time. Service users’ legal rights are protected by the systems in place, including a contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. The Old Vicarage Nursing Home, DS0000022358.V305418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25,26 The quality in this outcome area is adequate. This judgement has been made using a tour of the building, and discussion with staff. The home is clean and hygienic, safe and well maintained. However, some items of furniture are shabby, and in need of repair/replacement. EVIDENCE: The location of The Old Vicarage is conveniently placed for a care home. The external state of repair and maintenance is generally good, and the interior state of repair is at a satisfactory standard. Since the previous inspection two bedrooms have been refurbished and redecorated, and flooring to the shower room and laundry had been replaced/renewed. The acting Care Manager is aware that some bedroom furniture, and items of furniture in the lounge are in need of replacement furnishings. This has reportedly already been brought to the attention of the The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 17 Registered Person. Communal areas are adequately furnished, however some armchairs and small tables are shabby/worn/damaged and in need of replacement/repair. The dining room tables are bare, and need flowers and placemats to brighten up the room. Bathrooms and toilets are suitably equipped and adapted. The domestic services in the home were seen to be of a very high standard, much to the credit of the staff. The home was clean and tidy, with no malodours. The Old Vicarage Nursing Home, DS0000022358.V305418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is adequate. This judgement has been made using discussion with the acting Care Manager and staff, examination of the staff rota, and staff training/supervision records. The acting Care Manager confirmed that the home’s overall staffing coverage has improved, and the use of agency staff has been considerably less than at the time of the previous inspection. Staff must receive appropriate training in regard to their role and responsibilities, this must include up to date Fire training, POVA, and Dementia training. The home is registered for DE Dementia over the age of 60 years for 27 persons, however it is a shortfall that care staff have not had Dementia training. EVIDENCE: Staff rotas were examined, and 3 members of staff were interviewed. Staffing levels are based on the dependency levels of service users in the home and these are reviewed on a regular basis. Rotas showed that staffing levels have been maintained. The acting Care Manager confirmed that all staff now have recognised periods of rest during long shifts, and that there is also less reliance on agency staff to maintain staffing levels. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 19 Discussions with staff were positive, and showed a clear determination that they belong to a committed team. The home employs a full time administrator – shared with the sister home, and a part time gardener/maintenance person. The acting Care Manager confirmed that she in the process of applying to the Commission for Social Care Inspection (CSCI) in regard to Care Manager Registration, and also confirmed that there are currently 5 staff awaiting results of their undertaking the NVQ level 2 award, this will equate to 70 of care staff at the home, assuming that all will achieve the award. The home does not currently have a full and clear staff training schedule for the coming year, and individual training records for staff are not yet implemented. It is a requirement of this report that staff must receive training appropriate to their role and responsibilities, that a staff training schedule is completed and forwarded to CSCI, and that individual training records for staff are established. The home is registered for DE Dementia over the age of 60 years for 27 persons, however it is a shortfall that care staff have not had Dementia training. Staff training records show that training is required for staff in regard to Fire, POVA, and Dementia. However, there are plans in progress for specific training (amongst other courses) in wound care and palliative care. Staff spoken with and records seen confirmed that care staff are receiving regular supervision as per the National Minimum Standard. Recruitment practices are under review by the acting Care Manager and the Administrator for the home. This will be monitored at the next inspection. The Old Vicarage Nursing Home, DS0000022358.V305418.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 34, 35, 36, 38 Quality in this outcome area was poor. This judgement has been made using discussion with the acting Care Manager, residents, relatives and staff, examination of records. Feedback received from comment cards, and direct observation. The acting Care Manager is yet to be registered with the CSCI. Several issues have been highlighted as a result of this inspection relating to care planning, resident choice, staff training, POVA, and quality assurance. Requirements have been made in those areas. EVIDENCE: The acting Care Managers’ application is in the process of being completed and an interview will be arranged as soon as the documentation is received by CSCI. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 21 Ms Khadoo is fully aware of the task in hand to raise the overall standard of administration and care practices in the home, and the need for both a stable and strong management structure. Ms Khadoo has discussed her plans in relation to the home. She is pro-active in promoting good practice, and ensuring that staff have appropriate training. However, the home does not currently have a full and clear staff training schedule for the coming year, and individual training records for staff are not yet implemented. It is a requirement of this report that staff must receive training appropriate to their role and responsibilities, that a staff training schedule is completed and forwarded to CSCI, and that individual training records for staff are established. Staff training records show that training is required for staff in regard to Fire, POVA, and Dementia. The home is registered for DE Dementia over the age of 60 years for 27 persons, however it is a shortfall that care staff have not had Dementia training. Staff spoken with and records seen confirmed that care staff are receiving regular supervision as per the National Minimum Standard. Care records seen evidenced that residents’ health and personal care needs are being met. However, care plans seen were unsigned, and did not contain arrangements in the event of terminal illness, a social history, or details of residents’ preferences. Care plans must contain details of any specialist communications needs of the resident, and methods of communication that may be appropriate to the resident. They must also contain a record of any limitations agreed with the resident as to the resident’s freedom of choice, liberty of movement and power to make decisions. The inspector had received 2 of the ‘Have your say’ documents, which the CSCI issue to relatives, as well as 10 comment cards from relatives, health and other professionals. Comments received have been generally positive. two comments received reflected that there had been some improvements in standards at the home recently, (since the new acting Care Manager arrived). Relatives spoken with at the time of the inspection, and comment cards received have reflected their satisfaction with the services that they and their relatives have received. No relative or respondent had asked to speak to the Inspector. Personal monies held by the home for residents were randomly checked, and were in good order. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 22 Quality assurance is currently not being undertaken as per the National Minimum Standards, this was discussed with the acting Care Manager, and it is anticipated that a system for monitoring quality assurance will be devised and implemented within the next few months. This will be monitored at the next inspection. Ms Khadoo is in the process of undertaking risk assessments for all aspects and areas of the home, including personal and environmental risk assessment. She confirmed that all health and safety records are in place, and that these are up to date, including fire safety records. This will be monitored at the next inspection. The home’s Policies and Procedures were discussed, and shortfalls highlighted. These included POVA. The home must obtain a POVA policy and procedure, and provide training in this area for staff. It was said by the acting Care Manager that other policies highlighted may be either under review, held by the Administrator for the home, or by the sister home. This will be monitored at the next inspection. The Old Vicarage Nursing Home, DS0000022358.V305418.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 3 X 2 The Old Vicarage Nursing Home, DS0000022358.V305418.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. 1. Standard OP7 Regulation 15, Sch3 (l)(q) Requirement Care plans must contain details of any specialist communication needs and methods of communication that may be appropriate. Care plans must contain a record of any limitations agreed as to the service user’s freedom of choice, liberty of movement and power to make decisions. The registered person shall having regard to the size of the care home and the number and needs of service users Residents must be consulted about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including having regard to the needs of service users, activities in relation to recreation, fitness and training. Timescale for action 30/09/06 2. OP12 16, (2) (m)(n) 30/09/06 3. OP18 13(6) The registered person shall make 30/08/06 arrangements for service users – By training staff or by other measures, to prevent service users being harmed or suffering DS0000022358.V305418.R01.S.doc Version 5.2 Page 25 The Old Vicarage Nursing Home, 4. OP30 18(c)(i) 5. OP33 24 abuse or being placed at risk of harm or abuse. The registered person shall ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform. The registered person shall establish and maintain a quality assurance system for improving the quality of the service provided. 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP15 OP19 Good Practice Recommendations Care plans need to be signed by the service user or their relative/representative. Dining tables to have placemats and flowers to brighten the room. Shabby/worn/damaged furniture should be replaced/repaired. The Old Vicarage Nursing Home, DS0000022358.V305418.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Old Vicarage Nursing Home, DS0000022358.V305418.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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