Inspection on 10/09/05 for The Old Vicarage Residential Home

This inspection was carried out on 10th September 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Vicarage Residential Home 22/09/06

The Old Vicarage Residential Home 27/02/06

The Old Vicarage Residential Home 22/11/04

The Old Vicarage Residential Home 15/06/04

The Old Vicarage Residential Home 21/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The old Vicarage Residential Home Vicarage Road Tean Stoke On Trent Staffordshire ST10 4LE Lead Inspector Irene Wilkes Unannounced 10 September 2005 9:30 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 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 Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Residential Home Address Vicarage Road Tean Stoke On Trent Staffordshire ST10 4LE 01538 723441 01538 751242 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Patricia Ann Cope Miss Lisa Marie Shaw CRH 15 Category(ies) of DE(E) (3) registration, with number OP Old age (15) of places PD(E) Physical dis - over 65 (4) The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 November 2004 Brief Description of the Service: The Old Vicarage is a residential home for older people which is located in the small village of Upper Tean in Staffordshire. The property was built around 1859 as the local vicarage. It has been updated by the current providers to meet the national minimum standards. The property is 2 storey, serviced by a shaft lift, and provides 15 single occupancy rooms, with 12 of these having an en-suite facility. All bedrooms are lockable by the service users. Aids and adaptations are in place throughout the home to assist service users with restricted mobility, and there is an assisted bath on each floor, a nurse call system and ramp access to all external entrances. Bathrooms and toilets are close to bedroom and communal areas. There is a large lounge with small conservatory off, and a pleasant dining room, again leading to a small conservatory. All areas of the home are tastefully decorated and well fitted. There is a very homely feel. The kitchen is large and well equipped and there is a laundry attached to the side of the home, well away from food preparation areas. The property is surrounded by beautiful grounds that are well maintained. Car parking is available at the front of the property. Access to all healthcare services is available. The community is welcomed into the home, and family and friends can visit at any reasonable time. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a part day in September, on a Saturday. The registered manager was not on duty until later in the day, but both proprietors were on site and were available to assist with the inspection. The majority of service users were spoken with and a visiting relative also kindly agreed to discuss her views of the home. A care worker was also interviewed. The inspector was able to observe care being provided throughout the visit, and was also present when the lunchtime meal was served. Provision of medication to the service users was also seen. 4 service user care plans were inspected, 3 staff files and other documents were seen relating to staff training and aspects of the running of the home. What the service does well: All of the service users spoken with were very happy living at the home. A number said that while there was no place like your own home, living at the Old Vicarage was the next best thing. ‘The home is excellent.’ ‘Home would be best but this is the next best thing.’ ‘All of the staff are very good and kind, and do their best for everyone.’ The visiting relative, who had been visiting regularly for many years also confirmed that she had nothing but praise for the home, the proprietor and the staff team. Everyone said that the food was good. Some admitted that with varying tastes it was not possible to please everyone on all occasions, but they confirmed that the food was of sufficient quality and quantity to suit them, and that there were choices readily available if they did not like anything on offer. The kitchen was seen and it was very well stocked with a good range of fresh, frozen and tinned foods. It was considered that there were sufficient activities available with a range to suit most tastes. Service users said that they played bingo, had quizzes, that flower arranging demonstrations took place regularly, along with musical evenings and the celebration of events such as birthdays, Easter etc. The care plans seen showed that the individual interests of each service user had been recorded. There was no-one who said that they were bored or wanted to do anything any different, and several service users said that they were consulted regularly about the activities and if they suited. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 6 All of the service users said that the home responded very quickly if they felt unwell and ensured that the G.P. was called promptly where required. The care plans showed that the needs of each person were reviewed on a monthly basis with their involvement, and any additional equipment required, such as when mobility deteriorated, was quickly provided. The care plans also had good recording of any significant events relating to a service user on a day to day basis. Such records were clear, concise and relevant and showed that the needs of the service users were quickly responded to, which was also confirmed by everyone asked. All were happy with their environment. Each said that their bed and bedroom was very comfortable, and they were pleased to be living in such pleasant surroundings. What has improved since the last inspection? What they could do better: The risk assessments for service users as highlighted above need some improvement. A fire risk assessment for the building is necessary. While most of the documentation is in place relating to information required in the recruitment of staff, the home needs to fine tune this to include documentary evidence of identity, and a photograph of the member of staff is required. While the home ensures that all staff receive an induction programme, it was not clear if this meets the national training organisation’s requirements. The home needs to study the induction programme of the training organisation that can be found on the internet, to see if the home’s programme is sufficiently detailed. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 7 It became clear that the home does not undertake a formal supervision process of all staff. While senior staff are always available to provide support, the standards recognise that all staff can benefit from a regular individual meeting with someone more senior to discuss any areas of concern and their own care practice. This needs to take place at least 6 times per year. All of these areas are set out as requirements in the report, and the home has been given a timescale to complete them. The home is recommended to provide a hard back drugs register in which to record the administration of any controlled drugs. This is viewed as good practice. 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 Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 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 standard(s) 3 The home undertakes a full assessment of each prospective service users needs and gives confirmation in writing that the home can meet the assessed needs of the individual. This means that service users and their families gain confidence that the move to the home will be positive. EVIDENCE: 4 care plans were inspected, including 1 of a service user who was very recently admitted to the home. Each care plan showed clearly that a preadmission assessment had been undertaken that covered the full range of care needs, medication usage, mental state, social and recreational interests and family/friends involvement. The service user who was the newest admission to the home confirmed that she had been involved in providing information for the assessment. It was further verified that the home provided this confirmation in writing to the service user, and the proprietor also told the inspector that this was the case on every occasion. This home does not provide intermediate care, and so this standard was not assessed. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The holistic needs of the service users are met by the home. Medication procedures are sound and service users feel that they are treated with respect. This means that the service users are safe in the home, and they themselves are confident with the care provided, and are happy living there. EVIDENCE: Each of the 4 care plans sampled had clear information about the service users’ health, personal and social care needs. In each case there was a moving and handling risk assessment in place, and other risk assessments relating to individual need were available. The inspector discussed with the proprietor that the risk assessments would benefit from more extended information about how each risk would be managed. It became clear that appropriate steps were taken in practice, but that these steps need to be documented. This is a requirement of this report. The service users are fully involved in drawing up their plans, which are reviewed every month, also with their involvement. This practice was confirmed verbally to the inspector by the service users, and each review was also signed off by them. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 11 The monthly review recording, and also the recording of any significant events throughout the month were concise, relevant and provided a very clear account of issues relating to the service user that was very pleasing to note. The health care needs of each service user in the 4 care plans sampled were clearly addressed. There was no-one in the home with any pressure sores at the time of the inspection, but where this had been the case previously it was fully documented, with evidence to show that the relevant professionals had been involved at a very early stage. There was evidence throughout the home of appropriate equipment being provided for the promotion of tissue viability, e.g. propad mattresses, cushions etc. Each care plan showed that the service users had access to specialist medical, nursing, dental, chiropody and therapeutic services as required, and prompt referral to the G.P. regarding any concerns about the health of an individual was apparent. This was confirmed by a relative and her mother. Opportunities provided for appropriate exercise and physical activity were in evidence. For example at the visit 1 service user who had recently been in hospital and had difficulty in walking was being assisted with exercises by a member of staff following instruction from the physiotherapist. Another male service user took his usual walk outside around the grounds. A medication round was undertaken during lunch and the inspector observed this. The Venalink monitored dosage system of medication is used, and the provision of medication from dosette to the service user was appropriate, with discreet observation being made by the proprietor that the medication was taken. All aspects of medication storage, record keeping, disposal and medication review were appropriate. The pharmacist visits on a 6 monthly basis and written reports are provided to the home. These reports also confirmed the inspector’s findings from this visit. The storage and recording of controlled drugs was satisfactory. The inspector recommends the use of a hard back controlled drugs register. Most of the service users were sitting in the lounge throughout the morning, and were happy to speak to the inspector about their life in the home. Everyone was unanimous that the staff treat them with the utmost respect, and that they all respect their privacy. ‘The staff are excellent. They are all very good and kind and do their best for everyone.’ ‘Being at home would be best, but being here is the next best thing.’ A relative who visits regularly also confirmed that she always saw staff knocking on bedroom doors, on bathroom doors and assisting service users very discreetly to the bathroom to ensure their privacy. This was also noted by the inspector throughout the visit. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 12 Service users have access to the home’s telephone that is taken to them in their bedrooms should they wish to make a call. The proprietor confirmed that relatives also know that they can contact the home to speak to their relative and that the phone is taken to them to complete their call in private. The post was delivered during the visit and one or two residents received their mail, which was unopened. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 12, 13, 14, 15 The service users are encouraged to adopt a lifestyle that suits their individual preferences in relation to all aspects of their life in the home. They enjoy their meals, where again personal choice is afforded. This means that the service users are contented living in the home, and are enabled to exercise choice and control over their lives. EVIDENCE: A discussion was held with the service users and a relative about the activities in the home and if these were what they wanted and suitably frequent. The inspector was told that bingo was played regularly, they had quizzes, a flower arranger came monthly to do demonstrations, musical evenings were held, a key board player and sing song was regular, all their birthdays were celebrated with a party and seasonal activities, e.g. easter bonnet parade, etc. were undertaken. The service users also confirmed that some of them undertook individual activities, such as knitting, jigsaws, etc. and the inspector saw evidence in the care plans that a list of activities enjoyed by each resident was available in their care plan. The service users confirmed that they no longer wanted to go on trips out, unless in the car with their families, as they find this too tiring now. Each service user said that the range and frequency of planned activities suited them. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 14 The home is registered to care for 3 service users with dementia, and the inspector considered that sufficient thought had been given to provide activities to stimulate these service users, although reminiscence sessions may prove a useful addition to the range of activities available. A relative who was visiting confirmed that she was made welcome at any time that she visited, although she naturally tried to avoid mealtimes. She said that the home invited relatives to the musical evenings, etc, and there were also summer fetes and other fairs arranged where the community was invited to join in. All of the service users confirmed that their relatives and friends were always made very welcome by the home. The majority of service users handle their own financial affairs, or rely on relatives. Where the odd few ask the home to deal with their personal spending money they confirmed that the arrangements in place ensured that they could have their money when they wished. A sample of service users’ bedrooms were seen and these were each well personalised with private possessions brought in from home. All of the service users confirmed that they could rise and retire to their own choosing. A member of staff confirmed that a couple of people stayed up very late, and another service user liked a ‘lie in.’ Lunch was served during the inspection. The tables were attractively laid with serviettes and napkin rings, placemats etc. The dining room is very pleasant and the meal was a relaxed affair, with service users chatting to one another, to the staff and to the inspector. We had quite a discussion about the cricket match that a number of people were interested in, with 1 service user coming later for his meal, and leaving as soon as he had eaten it to go to watch the match again on his television. The lunchtime menu consisted of gammon and pineapple, cheese sauce, fritters, peas and broccoli, followed by apricots and custard or yoghurt. The service users had earlier in the morning confirmed that the meals were suitable in quality and quantity. Some recognised that people have varying tastes and so not all the meals suited them all of the time, but they also confirmed that they could have an alternative if there was something on the menu that they did not like. There was a board in the dining room showing the meals for the day, and this was up to date when the inspector arrived, and corresponded with what was served later at lunchtime. The menu book was seen. A 4 week rolling menu is in place. The meals recorded were ‘homely’ and nutritious, and the records also showed when alternative choices were made by a service user. There was also recording of individual intake by a service user whose weight was being monitored. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 15 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 standard(s) 16 and 18 Service users and their relatives know that the staff listen to them, and are confident that should they ever have cause to complain that this would be addressed appropriately. The home has appropriate procedures in place to safeguard service users from abuse. This means that service users feel that their right are protected and that they are safe in the home. EVIDENCE: The home has an appropriate Complaints Procedure that is available to service users via the Service User Guide and is also on display in the entrance to the home. The service users all said that they had never had cause to complain. If they had a concern about anything, which was rare, they discussed this with staff or the proprietor and the issue was resolved. A relative also advised the inspector that she was aware of the Complaints Procedure but had never had any cause to complain, and her mother had lived at the home for some 10 years. She also said that she would speak to the proprietor if she had any issues, who was very approachable and she knew that she would want to put any concern right. The home had received no complaints and there had been no complaints received by the Commission. At the previous inspection it had been evidenced that the home had a copy of the Staffordshire Inter Agency Vulnerable Adults Policy, and the home’s own The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 16 policy regarding the protection of vulnerable adults had been examined and confirmed as satisfactory. There was also a WhistleBlowing Policy available, and a policy regarding dementia which made reference to aggressive behaviour and appropriate management of behaviour associated with this condition. These documents were not inspected at this visit. Records and funds relating to service user’s own monies were sampled and were satisfactory. A member of staff was questioned about her understanding of abusive practice and how she would respond should she ever witness or be suspicious of any malpractice. The staff member had a sound understanding of the issues involved and of her reporting responsibilities. She also understood what would be expected of the care manager/proprietor should any issue arise. The inspector discussed the Protection of Vulnerable Adults (POVA) list with her. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 17 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 standard(s) 19 and 26 The home provides a safe, well maintained and clean and hygienic environment to protect service users from any environmental hazards. EVIDENCE: The home is a mature 2 storey detached property set within its own grounds in a quiet road just off the main village of Tean in Staffordshire. It provides 15 single occupancy bedrooms, with 12 of these having en-suite facilities. There is a tastefully decorated lounge and conservatory, with a separate dining room with a small conservatory area, and an assisted bath is available on each floor, that is in close proximity to bedrooms and communal areas. The home had grab rails provided in specific areas, and a nurse call system was in operation. Service users confirmed that the staff responded speedily when they called for assistance. There was sufficient storage space within the home for wheelchairs etc. The home has a shaft lift. The home had grab rails and ramps at external entrances. The spacious grounds were pleasant and free from hazard. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 18 The previous inspection had highlighted that there was 1 remaining radiator that required a guard to be fitted. It was seen that this had been addressed. The proprietor was unsure if a fire risk assessment had been undertaken. It is a requirement of this report that such an assessment is completed if this has not already been effected. The home has a record of maintenance in place identifying renewal of furnishings, equipment and general repairs undertaken within the home. This was an unannounced inspection undertaken at a weekend and it was clear to the inspector on arrival that the general cleanliness and hygiene of the home was to a high standard. A cleaner was on duty and she was seen throughout the day undertaking tasks to maintain the cleanliness of the home. There is a separate laundry area sited away from the kitchen. There is no sluicing facility provided within the home. This is considered acceptable, as the service users do not have a continence problem to any large degree. The home is reminded, however, to keep the needs of the service users under review in this context. Hand washing facilities and paper towels were provided throughout the home. The inspector discussed with a member of staff issues regarding infection control and was satisfied that appropriate procedures for the control of infection and the safe handling and disposal of clinical waste were in place at the time of the inspection, including the wearing of protective clothing. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home has sufficient staff to meet the needs of the service users and the recruitment of staff generally meets the standards. Some attention is needed to the finer details of the requirements to ensure that all aspects are covered. Staff receive mandatory training which assists them in their work. The home must ensure that the induction training in place at the home meets TOPSS requirements. The attention to employing the right staff who are well trained and in sufficient numbers means that the service users can be confident that their needs are appropriately addressed. EVIDENCE: There were 13 service users in the home at the time of this inspection, with 2 places vacant. The proprietor and a care worker were on duty until 3pm, and also a domestic. The other proprietor was also at the home for part of the visit. He attends to maintenance issues and other administrative duties as and when required. The staffing rotas evidenced that 2 people are on duty at each shift of 8am – 3pm, 3pm-10pm and 10pm until 8pm. This provides for a senior member of staff on duty at each shift (Care Manager, Senior Care Worker or Proprietor, when required) and a Care Worker. Both night staff provide waking night cover. The home also employs a part time domestic and a gardener. The proprietor does the cooking and is supported in the kitchen by various care staff, who each have their food hygiene certificates. The proprietor is appropriately qualified. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 20 At the previous inspection there was a requirement to review the dependency levels of the service users to ensure that the staffing hours were sufficient to meet the needs of the service user group. While this had not been addressed in any formal way, the proprietor advised the inspector that she provided additional cover at the home in support of the rostered hours should the needs of the service users increase. For example, they had recently had a bereavement in the home and for the period whilst the lady was ill before she died the proprietor had worked as the third member of staff on duty. The inspector asked the service users, a relative and a member of staff about their views on the numbers of staff available. All consulted said that they felt that there were always sufficient staff on duty. The inspector observed the running of the home throughout the visit and the demands placed on staff to meet the needs of the residents. It was considered that there were sufficient staff available to meet their needs in a timely manner. As is required of all homes, the manager is reminded to keep the ratio of staff available to appropriately meet the needs of the service users under regular review. 3 staff files were randomly selected and these evidenced that the information needed under the requirements of Schedule 2 of the Care Homes Regulations was mostly available. Documentary proof of identity was not available, neither were photographs of the staff, although the proprietor referred the inspector to a list put up on the staff notice board which informed staff that the latter was required. It is a requirement of this report that documentary proof of identity is retained in each staff file, as well as a photograph of the person. Following conversation, the proprietor was advised of the need to obtain a Criminal Records Bureau check, or where staff recruitment was urgent, to gain a POVA First check before any prospective member of staff started work at the home. This over-rides any previous arrangements agreed to safeguard individuals. The inspector was satisfied however that all of the staff currently working in the home had undergone a Criminal Records Bureau search. Other requirements made at the previous inspection, namely for staff undertaking the selection and recruitment of staff to complete equal opportunity training and to obtain a Criminal Records Bureau check for the volunteer gardener had been addressed. There was evidence in each staff file inspected that an induction programme had been completed. The home is required to check that the induction programme meets the TOPPS training requirements and to improve the induction training if this is not the case. Foundation training to National Training Organisation standards must be provided within the first 6 months of employment if the care worker has not commenced NVQ level 2 training by that date. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 21 Discussion with the proprietor evidenced that all mandatory training was up to date. Not all of the records were checked for documentary evidence of this, but moving and handling training, medication training, fire safety and training in infection control training records were seen and confirmed this for those subjects. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 36 and 38 Service users are safeguarded from financial abuse. From the selection of records examined it is considered that the health, safety and welfare of the service users is promoted and protected. However, the staff must receive regular formal supervision to further support them to meet the needs of the service users. EVIDENCE: The proprietor advised that the service users’ respective families manage their financial affairs, although the home assists some service users by keeping a small amount of funds for them to purchase small personal items. The record of transactions for these monies was sampled and they showed good record keeping, with full entries for money in and out, with the entries witnessed and signed by 2 members of staff. The balance of funds against entries was not inspected on this occasion. The money is securely kept within the safe. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 23 The home also has a Residents Fund, built up from fund raising events, to pay for additional social events etc. These records were also satisfactory. Questioning of a member of care staff found that the home does not provide formal supervision. This was confirmed by the proprietor. Supervision should take place at least 6 times a year and cover all aspects of practice, philosophy of care in the home and career development needs. Records of supervision should be made. The home is required to provide a programme of formal supervision for all of its staff, and to keep written records of these discussions. Sampling of a limited amount of records relating to health and safety was undertaken. This showed: Safe working practices were in place at the time of the visit for moving and handling; A care worker with an interest in health and safety undertakes regular audits in the home and provides written advice to staff to address any hazardous practices. The evidence seen and discussion with her showed that she had a good understanding of health and safety issues. There was correct storage and preparation of food. ‘Fridge and freezer temperatures were routinely recorded and regular food probing was in evidence; There was an up to date gas safety certificate; The water supply had been tested for Legionella and found satisfactory; COSHH (Control of Substances Hazardous to Health) requirements were followed in that all substances were in locked cupboards and the relevant data sheets were available; Accidents were appropriately recorded in an accident book that complied with Data protection; Fire safety checks were all completed and there was suitable training and evacuation practice for staff; The maintenance of hoists was up to date. The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 2 x 3 The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 25 YES 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 OP7 Regulation 13 Requirement Review the current risk assessments to provide more comprehensive information relating to potential hazards within the home and the community. This should include information relating to the appropriate control methods. (This was also a requirement from the previous inspection) Undertake a fire risk assessment for the building Ensure that all of the information as required under Schedule 2 of the regulations is maintained in every staff file. Implement a supervision programme for all staff Review the induction programme to ensure that it meets TOPPS requirements, and provide Foundation training within 6 months of employment Timescale for action 31/12/05 2. 3. OP26 OP29 23(4) 19 (4) & (5) and Schedule 2 18(2) 18(1) 31/12/05 31/12/05 4. 5. OP36 OP30 30/11/05 31/12/05 The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 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. Refer to Standard OP9 Good Practice Recommendations Provide a hard backed book to record administration of controlled drugs The old Vicarage Residential Home E51-E09 The Old Vicarage Res Home S5022 V248547 24.09.05 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Stafford - 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. 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