Inspection on 15/08/06 for The Old Vicarage (Staverton)

This inspection was carried out on 15th August 2006.

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 (Staverton) 12/08/08

The Old Vicarage (Staverton) 26/01/06

The Old Vicarage (Staverton) 09/09/05

The Old Vicarage (Staverton) 10/02/05

The Old Vicarage (Staverton) 27/10/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage (The) The Old Vicarage Staverton Trowbridge Wiltshire BA14 6NX Lead Inspector Thomas Webber Unannounced Inspection 15th August 2006 09:15 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 Old Vicarage (The) DS0000057134.V306923.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. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage (The) Address The Old Vicarage Staverton Trowbridge Wiltshire BA14 6NX 01225 782019 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) Equality Care Ltd Lucy Catherine Elizabeth Wilcox Care Home 21 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (5), Old age, of places not falling within any other category (21) Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated in the home at any one time is 21 No more than 5 service users aged 65 years and over with a mental disorder may be accommodated at any one time 26th January 2006 Date of last inspection Brief Description of the Service: The Old Vicarage is a privately owned residential care home offering accommodation and personal care to a total of 21 residents over the age of 65 who require care primarily through old age, although the home is also registered to accommodate 5 residents with a mental disorder that excludes learning disability or dementia. The services fees for the home range from £350 to £450 per week. The home is situated in the village of Staverton which provides limited amenities. However, its location is only approximately two miles from the County town of Trowbridge. The home has a number of car parking spaces available to the front of the property. The home is registered to Equality Care Ltd and the registered manager is Mrs Wilcox. The home provides all single accommodation for residents use and all but three of the bedrooms are provided with en-suite facilities. Residents bedrooms are located on the ground and first floor levels with residents having free access to all the communal areas and to their bedrooms. Three chair lifts have been installed to enable residents to access the various levels of the building. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted over a period of two days on 15th and 17th August 2006 from 09:15 to 16:00 and 10:00 to 15:20 respectively. The judgements contained in this report have been made from evidence gathered during the inspection, which included a tour of the premises and takes into account the views and experiences of fifteen of the twenty residents in situ, which were sought, on an individual basis. The views of the care manager, deputy manager, two members of care staff and one of the cooks were also sought. Twenty nine of the thirty eight Standards were assessed on this occasion which included examining records, staffing, care practices, systems, policies and procedures and feedback was provided throughout the inspection. What the service does well: The home is run and managed by persons who are appropriately qualified and have sufficient experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on aspects of the running of the home. Residents spoken to commented very positively about the care provided by the staff and described them as being good, helpful, kind, patient and brilliant. Staff were observed to undertake their duties in a warm, caring, supportive and attentive manner. The home is working towards achieving a trained workforce with staff receiving various levels of supervision. The home is accessible, safe and suitably maintained to meet the individual and collective needs of the residents. Residents are provided with individual bedrooms which they have personalised to their individual wishes. Residents have access to safe, comfortable and suitably furnished and decorated communal facilities together with sufficient toilet, shower and bathroom facilities. The home is maintained to a good standard being clean, tidy and comfortable and provides suitable laundry facilities. Residents spoken to commented very favourably about the standard and cleanliness of their bedrooms as well as the laundry arrangements in place, stating that their clothing is returned quickly and in good condition. Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. Assessments have been completed and copies have been received from other professionals, prior to admission, to ensure that the home can meet the residents’ needs. Residents have been provided with either a copy of the home’s written contract or placing authority’s terms and conditions depending on the funding arrangements. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 6 Care plans have been established for all but the most recent resident admitted, which clearly identifies their individual needs. Residents’ health care needs are being suitably met. Residents’ privacy and dignity are respected at all times. Opportunities are available for residents to pursue their social, religious and recreational activities and residents exercise personal autonomy and choice within their capabilities. Residents maintain contact with their families, friends and relatives in accordance with their individual preferences and circumstances. Residents receive a varied, appealing and balanced diet. The menu provides a choice at all mealtimes and the vast majority of residents commented very favourably about the quality and quantity of food provided stating that they receive plenty and confirmed that a choice is available. However, a few residents did express some dissatisfaction about the quality of meals at times and the care manager has and will continue to monitor these. The main meal the day was observed and it was conducted in a relaxed and congenial manner where staff were on hand to support those residents who required it. Information is provided to residents on how to complain should they wish to and residents are confident that any complaints/concerns would be listened to, taken seriously and acted upon. Appropriate procedures are in place to protect residents from abuse. Residents’ financial interests are being suitably maintained. The health, safety and welfare of the residents and staff are being promoted and protected. What has improved since the last inspection? What they could do better: The number of care staff available during the afternoons is, on occasions, insufficient to provide direct care to the residents. The home needs to ensure that all new staff employed by the home is appropriately checked before they commence work so that residents are supported and protected by the home’s recruitment practices. Some deficiencies exist in the recording of medication administered. The home needs to ensure that staff always initial or enter the appropriate symbol in residents’ drug sheets and two members of staff always initial hand written medication records. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 7 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. Old Vicarage (The) DS0000057134.V306923.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 Old Vicarage (The) DS0000057134.V306923.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): 2, 3, 5 and 6 This judgement has been made from evidence gathered both during and before the visit to this service. Residents have been provided with a copy of either the home’s written contract or placing authority’s terms and conditions. Assessments have been completed and received from other professionals, prior to admission, to ensure that the home can meet the residents’ needs. Opportunities are available for prospective residents and their families to visit the home, prior to admission, to assess the quality of facilities and suitability of the home. Quality in this outcome area is good. EVIDENCE: Documentary evidence was available to confirm that all three residents most recently admitted to the home, had received a copy of the home’s written contract. Residents funded by social services are provided with a copy of the placing authority’s terms and conditions. Written evidence was available to confirm that the home had completed its various assessment tools in addition to having received a copy of the hospital assessment or mental health assessment in relation to all three residents case tracked by the Commission. As part of the home’s admission procedure, Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 10 evidence was available to confirm that the home had written to the residents/ next of kin to confirm that the home could meet the residents’ needs. Opportunities are available for prospective residents and their families to visit the home as many times as they wish, prior to admission, to assess the quality of facilities and suitability of the home. The care manager reported that two of the three residents visited the home whilst only the family of the third resident made pre-visits. The home does not provide intermediate care therefore this Standard is not applicable. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 11 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 and 10 This judgement has been made from evidence gathered both during and before the visit to this service. Care plans have been established for all but the most recent resident admitted, which clearly identifies their individual needs. Residents’ health care needs are being suitably met, although some deficiencies exist in the recording of medication. Residents’ privacy and dignity are respected at all times. Quality in this outcome area is adequate. EVIDENCE: Care plans have been established for all but the most recent resident admitted and those checked were good in content, informative and suitably written. However, the care manager was advised of ways to improve them by including residents’ preferences and choices in relation to the home’s routines. The care manager has also agreed to ensure that residents’ care plans are drawn up promptly on completion of their assessment. Manual handling, waterlow, nutritional and risk assessments have also been established for each resident as well as a dependency profile. However, the care manager will ensure that all documentation is appropriately signed and will also undertake a review of all residents’ risk assessments with a view of developing the level of content. Evidence was available to confirm that residents’ care plans are internally reviewed by the home, which involves the resident and key worker. This Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 12 process occurs on a monthly basis or where changes occur. The other assessment documents are also reviewed internally either on a monthly or three monthly basis depending on the document. Residents’ placements are formally reviewed initially after four to six weeks, then six monthly and thereafter yearly. Evidence was again available to confirm that this process involves all interested parties. The minutes of the review checked was well documented, although discussion was held about the need to record in more detail both residents and their relatives’ views. Residents admitted to the home are registered with one of five different surgeries. At the time of the inspection, all doctors’ appointments and district nurses’ appointments are held within the home with any examinations/ treatment being undertaken in the privacy of the resident’s bedroom. Residents spoken to confirmed this. Residents are provided with an option of having a member of staff present or not during these appointments. District nurse records are maintained within the home. Appropriate aids are provided for those residents with incontinent and/or mobility problems. Residents access and receive domiciliary visits from other health care professionals such as an optician, chiropodist and a massage therapist. Dental appointments are arranged as and when required. On the day of inspection, none of the residents were deemed capable of selfmedicating, although one resident was administering her own eye drops. However, residents who are deemed capable following a risk assessment and who wish to could maintain control over their medication. Staff only administer medication to residents once they have been deemed competent by management following internal training. A number of staff have also attended external training in respect to the administration of medication and there are plans for more staff to undertake such training. Examination of residents’ drug sheets showed that there were occasions where staff have not initialled or entered the appropriate symbol for when medication was administered. In addition there were also occasions where the practice of (hand written) medication records received into the home were not always being initialled by two members of staff. During the course of the inspection, the care manager implemented a robust system of monitoring to address the deficiencies identified. The home uses the Lloyds monitored dosage system for this purpose. A suitable recording system has been established for the receipt and disposal of unwanted medication. Residents are provided with their own single bedroom where they can conduct all their personal affairs in complete privacy. All residents have the option of having a telephone installed in their bedroom, which is linked to the home’s main telephone system and a number of them have availed themselves of this facility. Residents are charged a fee for this facility and any calls made by them are subsidised by the home. Alternatively, residents have the option of using the home’s handset in the privacy of their bedroom. Residents’ mail is given directly to them unopened, unless prior agreement has been reached Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 13 between residents and their next of kin. Residents spoken to confirmed these arrangements. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 14 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 and 15 This judgement has been made from evidence gathered both during and before the visit to this service. Opportunities are available for residents to pursue their social, religious and recreational activities and residents exercise personal autonomy and choice within their capabilities. Residents maintain contact with their families, friends and relatives in accordance with their individual preferences and circumstances. Residents receive a varied, appealing and balanced diet. Quality in this outcome area is excellent. EVIDENCE: From observations and discussions with residents, it is apparent that they can choose where and how to spend their time, including rising and going to bed. Residents have the opportunity to pursue their own individual interests as well as being able to participate in the various organised activities arranged by the home should they wish to. Written evidence confirms that the amount of organised activities arranged by the home varies from week to week. Some residents confirmed that they attend these with others preferring their own company: watching television, reading or listening to music. In addition, a hairdresser visits weekly, the Church of England vicar provides communion at the home on a monthly basis and a Catholic priest also visits fortnightly. The home supports and encourages residents to maintain contact with their families and friends and an open policy with regard to visiting has been Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 15 established. Residents can choose whom and where to see their visitors, either in the privacy and comfort of their own bedrooms or in the communal rooms available. These arrangements are referred to in the home’s service users’ guide and were confirmed by residents spoken to. Observations and discussions with some residents confirmed that they can exercise personal autonomy and choice within their capabilities. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely, they can choose what time to get up and go to bed, where to spend their time, where to eat, and what activities to participate in. They can handle their own financial affairs in the privacy of their own bedrooms, where they are capable. Residents spoken to confirmed that staff encourage and promote residents to maintain their independence according to their ability. A varied and satisfactory four weekly menu is in operation, which provides a choice at all mealtimes, including a cooked meal for their breakfast for those who wish it. The main meal of the day also provides a vegetarian option as well as the option of a salad particularly during the hot weather. Mealtimes are flexible and breakfast can be taken up to 11:00 and special arrangements can also be made for residents to have either early or late meals at lunch and suppertime. Residents’ dislikes are sought and recorded on admission. Drinks and snacks are also available at other set times of the day. Residents can choose where to eat their meals, although they are encouraged to use the dining room for their main meal as part of socialisation. The vast majority of residents spoken to commented very favourably about the quality and quantity of food provided stating that they receive plenty and confirmed that a choice is available. However, a few residents did express some dissatisfaction about the quality of meals at times and the care manager has and will continue to monitor these. The main meal of the day was observed and it was conducted in a relaxed and congenial manner where staff were on hand to support those residents who required it. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 16 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 and 18 This judgement has been made from evidence gathered both during and before the visit to this service. Information is provided to residents on how to complain should they wish to and residents are confident that any complaints/concerns would be listened to, taken seriously and acted upon. Appropriate procedures are in place to protect residents from abuse. Quality in this outcome area is excellent. EVIDENCE: A satisfactory complaints procedure has been established by the home and residents have been provided with a copy of this procedure. The home records and responds promptly to any complaints and concerns received, however minor and this was evident during the course of the inspection. The home operates an open and transparent policy and as a result all complaints/concerns are treated in the same way regardless of whether they are minor or more serious. Residents commented that they had no concerns/complaints, although they were adamant that if they did they felt confident in discussing any issues of concern with the care manager or staff. The home has established procedures for responding to suspicion or evidence of abuse and has obtained a copy of the Department of Health Guidance “No Secrets”. In addition, the home has obtained a number of copies of the shortened version of the Swindon and Wiltshire Vulnerable Adults procedures, which is in line with the Department of Health’s guidance document. Copies of this document have been distributed to all staff and some are also displayed within the home. New staff cover the issue of abuse during their induction and all staff receive ongoing training in this area which was confirmed by staff, the Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 17 training officer and the care manager spoken to during the course of the inspection. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24 and 26 This judgement has been made from evidence gathered both during and before the visit to this service. The home is accessible, safe and suitably maintained to meet the individual and collective needs of the residents. Residents are provided with their own bedrooms which they have personalised to their individual wishes. Residents have access to safe, comfortable and suitably furnished and decorated communal facilities together with sufficient toilet, shower and bathroom facilities. The home is maintained to a good standard being clean, tidy and comfortable and provides suitable laundry facilities. Quality in this outcome area is good. EVIDENCE: The home is well maintained throughout and there is an ongoing maintenance programme to enhance the residents’ living environment, which was evident during the inspection. The premises provide sufficient heating, lighting and ventilation and the standard of furnishings, fittings and decoration are suitably maintained. Radiators have been covered for the protection of residents and the type of construction used has been adapted to enable residents can regulate these for themselves. Residents have free access to the communal Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 19 rooms and to their bedrooms. A call bell system is installed in each room, which can be used by residents to call for staff assistance. Residents commented that staff respond appropriately and quickly to any calls. Three chair lifts have been installed to enable residents to access the various levels of the building. The home provides sufficient communal rooms which are comfortable, suitably furnished and decorated and include a lounge that leads to a conservatory together with a large, separate dining room. The home provides sufficient bathrooms, shower and toilet facilities, which meet the needs of the residents. There are three assisted bathrooms, one wheel in shower room and five separate toilets available, which are suitably located on both the ground and first floor levels. These facilities do not include those toilets located within the bathrooms and the en-suite facilities located within residents’ bedrooms. The home provides all single accommodation for residents’ use which all meet the national minimum standard of 10 square metres each and all but three bedrooms are provided with en-suite facilities. Residents’ bedrooms are located on the ground and first floor levels and are serviced by chair lifts. Residents’ bedrooms vary in size but are suitably furnished and equipped to ensure comfort and privacy. Residents can and have brought items of furniture and personal possessions to make their bedrooms more homely and they have personalised them to their individual wishes. Locks have been fitted to residents’ bedroom doors. Planned admissions would be able to choose the colour of decoration to their bedrooms as well as those residents who have been at the home for a long time, particularly where a bedroom needs redecorating. Residents spoke positively about the standard and cleanliness of their accommodation. The home continues to be maintained to a good standard being clean, tidy and free from offensive odours. The laundry room provides suitable facilities to meet the needs of the home. Residents’ clothing is labelled to ensure that their garments are appropriately returned. Residents spoken to commented very favourably about the laundry arrangements in place stating that their clothing is returned quickly and in good condition. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 20 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 and 30 This judgement has been made from evidence gathered both during and before the visit to this service. The number of care staff available during the day is, on occasions, insufficient to provide direct care to the residents. The home is working towards achieving a fully trained workforce. The last member of staff employed by the home was not appropriately checked before commencing work and therefore residents are not always supported and protected by the home’s recruitment practices. Quality in this outcome area is adequate. EVIDENCE: The deployment of staff continues to provide four members of care staff on duty in the mornings with only two on in the afternoons from 14:45 to 17:00 and three on in the evenings. Since the inspection, the home has, where possible, increased the staffing levels to ensure that there are also three members of care staff on in the afternoons. However, further part time staff will need to be employed to ensure that the increased staffing levels are maintained in the afternoons throughout the week. There are two members of waking night staff on duty with one member of care staff sleeping in each night. The above staffing levels exclude those hours worked by the registered manager and the number of ancillary staff employed. The care manager reported that there has been minimal staff turnover since the last inspection. Residents spoken to commented very positively about the care provided by the staff and described them as being good, helpful, kind, patient and brilliant. Staff were observed to undertake their duties in a warm, caring, supportive and attentive manner. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 21 The file of the newly appointed member of bank staff employed since the last inspection showed that appropriate recruitment practices are not being followed for the protection of the residents. Although a full employment history, medical clearance and two satisfactory references had been achieved (albeit one being a verbal reference), the member of staff had been employed before a satisfactory CRB in respect to her employment at The Old Vicarage together with two satisfactory written references had been obtained. The care manager agreed not to use the member of staff concerned for any more shifts until such time as all appropriate checks had been received. Evidence was available to confirm that the home is using the induction booklets, known as ‘Training Record of Induction and Competence in Care’, for all new staff employed. The home continues to support staff in either obtaining or working towards achieving training in NVQ at various levels in order to obtain a trained workforce. At the time of the inspection, the home had achieved approximately 75 . In addition evidence was available to confirm that staff attend other relevant training as well as the required various mandatory courses. Six staff have also achieved the A1 Assessors’ course. An ongoing training programme for the year has been established. Staff spoken to commented positively about the training opportunities available to them. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 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 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, 35, 36 and 38 This judgement has been made from evidence gathered both during and before the visit to this service. The home is run and managed by persons who are appropriately qualified and have sufficient experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on aspects of the running of the home. Residents’ financial interests are being suitably maintained. Staff are being supervised. The health, safety and welfare of the residents and staff are being promoted and protected. Quality in this outcome area is good. EVIDENCE: The registered manager is one of the co-proprietors of the company and has achieved the City and Guilds Advanced Management in Care qualification and NVQ 4. She has considerable management and supervisory experience and is complemented and supported by a care manager and two deputy managers who are responsible for monitoring the day to day care of the residents. The care manager has recently completed the Registered Managers’ Award but is Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 23 waiting for her award to be verified and has nearly completed the NVQ 4 in Care. Discussions with staff and residents indicate that residents benefit from an open, positive and inclusive atmosphere within the home where management communicate with a clear sense of direction and leadership. Staff morale is good and staff commented very positively about the level of support and the very positive and relaxed atmosphere within the home. The staff work very well as a team and staff and residents confirmed that the care manager is very approachable. Regular staff meetings and daily hand over meetings occur which enable staff to be kept up to date. Residents feel able to discuss any issues or concerns they may have with the care manager and staff and feel these would be suitably dealt with. At the time of the inspection, resident meetings are held twice yearly although the care manager is considering increasing this frequency and may introduce residents/relative meetings with the residents’ agreement. The home has secure facilities for the storage of residents’ monies. A spot check was carried out in relation to the system and monies held by the home on behalf of the residents. Although a few amendments were necessary in respect to some recordings of residents’ cash sheets, these were updated during the course of the inspection but residents’ monies were found to be satisfactorily maintained. There are a range of mechanisms in place for the care manager to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include daily handover meetings, regular staff meetings, informal and formal staff supervision. Written evidence was available to confirm that staff are formally being supervised and the care manager is considering ways to increase the level of frequency. Safe working practices have been established within the home, which complies with the relevant legislation. Policies and procedures are in place to ensure a safe working environment. The Environmental Health Officer carried out a health and safety inspection on 25th January 2006 and the care manager reported that minor recommendations made have been satisfactorily addressed. Staff continue to receive ongoing training in relation to health and safety and other mandatory courses. Radiator covers have been fitted to all radiators for residents’ protection and window restrictors have been fitted to windows above the ground floor. Examination of the fire log book showed that, in the main, it is being suitably maintained, although there was no recorded evidence to confirm that the emergency lighting had been tested by the home for March, May and July 2006. Written evidence was available to confirm that other tests and servicing had taken place to various equipment, gas and electrics. A tour of the premises did not identify any health and safety issues. Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 3 3 3 4 3 X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 X X 3 3 X 3 Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Timescale for action The registered individuals must 08/09/06 ensure that all (hand written) medication records are initialled by two members of staff. The registered individuals must 08/09/06 ensure that staff always initial or enter the appropriate symbol for medication administered. The registered individuals must 30/09/06 undertake a review of the numbers of care staff providing direct care to the residents and report back to the Commission with their proposals. The registered individuals must 30/09/06 ensure that appropriate recruitment practices are followed in respect to all members of staff employed. Requirement 2. OP9 13(2) 3. OP27 18(1)(a) 4. OP29 19(1)(b) Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Old Vicarage (The) DS0000057134.V306923.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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