Inspection on 21/02/06 for The Vicarage

This inspection was carried out on 21st February 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 Vicarage 26/04/07

The Vicarage 19/10/05

The Vicarage 21/03/05

The Vicarage 11/05/04

The Vicarage 28/01/04

Similar services:

2 Perhaver Park

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 The Vicarage 59 Andover Road Tivoli Cheltenham Gloucestershire GL50 2TS Lead Inspector Kath Houson Unannounced Inspection 21st February 2006 09:30 The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 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 Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Vicarage Address 59 Andover Road Tivoli Cheltenham Gloucestershire GL50 2TS 01242 521918 01242 227646 thevicarage@gloucestershire.gov.uk 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) Gloucestershire County Council Mrs Judith Metcalf Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5), Physical disability (5), of places Physical disability over 65 years of age (5) The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Vicarage provides respite care for guests’ with learning difficulties. The facility is owned and operated by Gloucestershire Social Services. The home is a large detached two-storey house based in the local area of Tivoli and has easy access to Cheltenham town centre, the house is secluded and set within its own grounds with a pleasant garden at the rear of the building which additionally has wheelchair access for users. Sensitive adaptations have been made to accommodate individuals with physical disabilities. The premises has five very large bedrooms four of which are en-suite. There is an additional bathroom and shower room. There is also a large communal lounge dinning room, spacious kitchen. The large hallway is comfortably furnished into a quiet space where guests can sit and is close to the telephone for guests’ to have conversations in relative comfort with the added option to take private calls into their rooms with mobile phones. Guests were observed using this part of the house, which looked welcoming. There is an intercom system available on request. All rooms have fitted furniture, colour TVs, portable CD, tape and radio player. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place one day in February 2006. The registered manager was available throughout the inspection and able to assist and provide all relevant documentation on request. Twenty-two core and noncore standards were assessed and included an examination of documentation; three care plans were case tracked, a tour of the environment and a short succinct feedback was given to conclude the inspection visits. The staff team were participating in a medicine educational day; no residents were present at the home during the current inspection. A short discussion was held with a staff member who works at the day centre, which the residents regularly attend. The inspector would like to extend her thanks to the staff for their assistance with the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home continues to operate at an extremely high standard; no recommendations or requirements were made on this occasion. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 6 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 Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Guests are provided with relevant information to make an informed choice about their place of residence. EVIDENCE: An information booklet was contained in three of the care plans that was seen. This booklet includes the relevant information about the home. The manager who will make a special home visit to assess the potential guest if this is requested or deemed necessary as part of the assessment process This process is significant as it takes into account the needs of the individual and what the service can offer. It is at this point a match is made between the service and the potential guest. The manager does become involved from the outset with the full assessment process to ensure that only people whose needs can be met are admitted. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 9 Multiple agency correspondence was seen as evidence and demonstrates partnership working across organizations. The information booklet is detailed and provides the aims and objects of the service provided which is beneficial for all guests and to make an informed choice about their respite stay. Each admission into the Vicarage has a service user file which contains detailed information ranging from next of kin, to individual tastes. The individual needs and aspirations are discussed with a named support worker with additional assistance from an advocate, family or representative. A matrix of matched support carers was seen as evidence and contained in the office. This ensured that the confidentiality issue is addressed. The assessed needs are individualised and personalised to each guest, and aim to make sure that the stay at the home is both memorable and enjoyable. Each of the three files seen had a service agreement that states the terms of the service, how much respite the individual has been allocated and any relevant addresses. The information within each file is regularly updated and information is available in a number of different formats to allow for accessibility for all users of the respite service. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9, and 10, Documentation and record keeping for the guests is organised and in excellent order. EVIDENCE: Care plans show how individual needs are met and all the guests remain registered with their GP. However the daily care during respite period is managed with a support care worker and the guest. Each item of care is documented, for instance; a guest regularly attends the day centre that may have a variety of projects in which guests can participate during the respite stay. Evidence taken from an informal discussion with a member of staff who said that the guests if they wish to can participate in a gardening project which is currently ongoing in the community. Additionally, care plans are consented with each individual guest with a pictorial communication sheet. A package of The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 11 care is designed around the guest during their stay and is consented with the assistance of the support worker. The aim of the communication sheet is to open the channel of communication between all agencies involved in the package of care process, also to encourage non-verbal guests to share their views. As part of risk taking and promoting independence the home support all guests to take part in activities. Care plans show risk assessments made in relation to identified hazards. Guests are given training on how to manage their own risk and personal safety, such as guests will take part in factory work that involves counting of screws and or nuts and bolts and placing them in packets, although this is done at the day centre activities are risk assessed with regular support from the home. Another example, guests take part in the fire training within the home. Guest is given both verbal and symbolic versions of the fire procedures and physically participates in the fire training within the home. This is a demonstration of guests managing their own risks with support from a committed staff team. Information about the guests is handled confidentially; all files are kept in the office in a secure place. The home has written policy on confidentiality that is signed by staff to ensure that all is in agreement with its content. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the 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 and 15 Guests are able to take part in culturally appropriate activities in a variety of venues. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 13 EVIDENCE: The home coordinates the transportation to ensure that all the guests arrive at the appropriate day care destination. Guests have a variety of venues to attend for the day’s activities. Each venue has a different topic in which the guests can take part according to their choice. For instance, Berkeley Court has programmes around individual skills, and has its links with Windows, which is a day centre. This centre provides a wide range of activities, such as Café/sandwich bar where work experience in food hygiene, food preparation is available. All activities are tailored to meet individual needs, with outcome focused care plans and in-depth assessments to monitor improvements at the day centre. The staff team support the guests during their respite stay to become involved in the local community. This has been demonstrated in a number of ways such as regular attendance in day centres, maintaining regular contact with families and advocates. During the half term the home ensures that activities take place, as seen in the homes activities book. This book shows that guests have a wide variety of choice and the ability to make new and maintain existing friendships are continued. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 21 Guests receive personal care and support in the manner to which they prefer. EVIDENCE: Guests who stay at the Vicarage are supported with their personal care in the manner which they prefer. This includes religion and the home has a policy that all guests have the right to follow their religious standing and support is given to ensue that guests can attend services of their choice. In addition to this personal support is provided with a support worker who will work alongside the guest during their stay. Care plans show that contact with support worker is regular and occurs on a daily basis. Care plans also demonstrate that emotional and physical needs are met. For example, during a previous inspection evidence was seen regarding how staff interact with guests in a sensitive and dignified manner. The manager herself The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 15 shows warmth consideration with all guests and entered into a discussion about their day’s activities. The home also has a procedure in preparation for dying and sudden death. A guest developed a long-term illness. The manager of the home was able to meet the dying wishes of the guest that was to ensure that they were to have a good time before they had passed away. The evidence was captured in the home’s policy and procedure operations booklet, which contains detailed guidance. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Guests are introduced to the homes complaints procedure both verbally and in writing. This information is also shared with families and advocates. EVIDENCE: The home has leaflets and available posters at the vicarage detailing the Gloucestershire County Council complaints procedure. A complaints procedure was also found in each guests file in a number of formats. Families and advocates are extremely satisfied with the service provided by the manager and her staff. The home continues to receive compliments about the service provided at the home over the last 11years. This is evident of the high standard that is maintained consistently for a long period of time. The staff team is small and continues to undertake training offered by the Department of Social Services. During the current inspection training was taking place. At the end of the days training the staff continued to discuss the day’s subject. The staff team will be participating in a new adult protection course that is running monthly. Topics include self-harm and issues of abuse. Although the The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 17 manager received the information late the manger applied immediately to put her staff team onto the course. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is comfortably decorated to a high environmental standard that exceeds the national minimum standard. EVIDENCE: The guests have the opportunity to stay in a suitably decorated home that exceeds the national minimum standard; each room has an individual home entertainment system, with the option to have a bedroom key. The fixtures and fittings are of high standard and quality and warmly contribute to the homely décor. Each bedroom far exceeds the minimum standard with ample living space. The home is safe and had security lights on the outside of the The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 19 house and secluded grounds. The home is clean, hygienic and free from any offensive smells. The building is well maintained and has a regular maintenance programme. Daily cleaning of fridge, freezer and cupboards for instance are documented regularly. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 and 35 A small well-trained staff team who are dedicated to providing an excellent quality of care during the respite stay supports the guests. EVIDENCE: The staff team is small and well trained. The manager ensures that every opportunity is taken to undertake training, to improve staff development and skill. Training and development is continuous which allows staff to grow and further develop their diverse skills to meet the needs of a wide population of service users. The home has a training and development folder that was seen as part of information gathering. The manager operates a thorough recruitment process to ensure that the protection of the guests is consistent and compliant with the regulatory requirements. Evidence obtained from staff files show enhanced CRBs, The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 21 references, and job descriptions, additionally the files contain training courses undertaken. One staff member had recently passed the LDAF course. Other members of staff are now pushing to complete their courses within the year. The staff team have a wealth of expertise and staff qualifications are high to further make sure that the standard of care that guests receive remains consistently of high quality. For instance more than 50 of the overall staff team are qualified to NVQ levels 2/3. The average length of time that the staff team remain at this home is 6.5 years. All the staff team have a working knowledge of Makaton, which is a regularly used sign language. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 The home fulfils its stated purpose and objectives and exceeds the national minimum standards in meeting the needs of the guests; who maybe receiving planned and emergency respite stay. The home continues to operate to an exceptionally high standard that would be of benefit to the guests. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 23 EVIDENCE: The manager of the home has demonstrated for several years that she is competent and fosters an atmosphere of openness and respect in which family, friends’ advocates and staff are valued and that their opinions matter. This is evident in the overall performance of the home during the current inspection and based on previous inspections. The manager was able to provide all relevant polices and procedures on request during the current inspection and was able to provide additional information when required, such as the electronic copy of the protection training. This was produced often on an ad hoc basis during a question and answer section during the current inspection. Effective quality assurance and monitoring of the service was seen in the positive feedback forms from guests and advocates and show how satisfied they are with the service provided. The health safety and welfare of the guests are promoted. The manager has completed a recent Third Tier Health and Safety Policy for the home. A copy was provided and contains detailed description of every aspect of the home. The policy has named responsible individuals who are qualified to perform first aide skills. The policy, which has been implemented in the home, also highlights hazards with control measures put in place to apply safety measures. The manager ensures that the home is regulatory complaint safe, homely and comfortable for guests who choose to spend their respite stay at the Vicarage. The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 4 2 4 3 X 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT Standard No Score 37 4 38 X 39 4 40 X 41 X 42 4 43 X 4 X X 4 4 LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Vicarage Score 4 4 X 4 DS0000037184.V292096.R01.S.doc Version 5.1 Page 25 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Vicarage DS0000037184.V292096.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!