Inspection on 25/11/05 for Vallance Rest Home

This inspection was carried out on 25th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Vallance Rest Home 16/10/07

Vallance Rest Home 11/05/06

Vallance Rest Home 03/05/05

Vallance Rest Home 07/10/04

Vallance Rest Home 18/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Vallance Rest Home 7/9 Vallance Road Hove East Sussex BN3 2DA Lead Inspector Jane Jewell Unannounced Inspection 10:00 25 November 2005 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 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. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vallance Rest Home Address 7/9 Vallance Road Hove East Sussex BN3 2DA 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) 01273 326053 Vallance Organisation Limited Mrs Maria Teresa Mirza Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of people accommodated must not exceed nineteen (19) The people accommodated must be aged 65 or over on admission Date of last inspection 3rd May 2005 Brief Description of the Service: Vallance Rest Home is a privately owned residential home, which has been owned and managed by the same family since 1980. The home is registered for up to nineteen older people over the age of 65 years. The premises consist of two Victorian houses converted into one. The home is presented across two floors ground and first floor, with access to the first floor via chair lifts or stairs. Resident accommodation consists of eleven single and four shared bedrooms with three bedrooms having ensuite facilities. Communal facilities including two interlinked lounges and a dinning room. There is a small rear garden with the front mainly paved to provide some off road parking. The home is located within walking distance of Hove sea front, local amenities and bus routes into Brighton. The homes literature says that it aims to provide a warm, comfortable, secure and above all caring environment for all its clients and where appropriate and all staff. The owners are active members of the Registered Care Homes Association (RCHA) and the National Care Homes Association. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken between 10am to 3 pm. The inspection was undertake with Mrs M Mirza (owner/manager) and there were nineteen older people in residence. The inspection involved a tour of the premises, examination of the homes records, and consultation with the staff on duty and residents. The focus of the inspection was to look at the experiences of life at the home for people living there. Since the last inspection CSCI’s pharmacy inspector has undertaken a monitoring visit to the home to assess the progress made towards meeting shortfalls in medication practices noted during previous visits to the home. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? Significant progress had been made towards addressing shortfalls in practices noted at previous inspections. This has improved resident’s safety through improved practices in medication, infection control and some aspects of fire safety. A new laundry room has been provided which has improved the system for laundering clothes. There is a much clearer sense of management leadership and direction, which has enabled residents to receive consistent quality care. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 6 Staff training has improved and has benefited from better planning and resources. Standards of administration and record keeping continue to improve which underpins the homes practices. What they could do better: There remain outstanding requirements relating to the monitoring of hot water and fire safety, which have remained unmet for some time. Continuing failure to address these will now result in legal advice being sought. Further positive steps must also be made to address outstanding requirements relating to medication, infection control and dementia training in order to improve resident’s safety and staff skills. Standards of cleanliness were variable with improvements needed to the cleanliness in some bedrooms. The trip hazard present in a bedroom required urgent attention. Following the draft inspection report no action plan was provided by the provider, detailing the action to be undertaken to address the shortfalls in practices noted in this inspection report. 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. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 The home provides both prospective and existing residents, with information about the services provided and what to expect when living at the home. Residents move into the home following an assessment of their needs. The home is able to evidence that it can meet most needs of residents. EVIDENCE: There is a range of information about the home and the services it provides, this includes a statement of purpose and service user guide, which have been given to residents and prospective residents, their representatives and other interested parties. Residents are provided with a written contract of terms and conditions of residency with the home. This can be used with residents and their families to make explicit the placement arrangements and clarify mutual expectations around rights and responsibilities. A signed copy of the contract is retained in resident’s files. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 9 Documents were examined relating to a recent admission. Copies of social services needs assessments were obtained prior to the resident’s admission. In line with previous recommendations a written format had been developed for the home to record its own assessment of prospective residents. This had been completed by the manager and provided sufficient information to help inform the decision as to whether needs could be met at the home. It was discussed that the record of the homes assessment should be signed and dated by the person undertaking it. There remains a range of needs amongst residents including some who have developed confusion or need considerable physical support to others who are independent. Requirements have been made over the course of several inspections that staff undergo training in Alzheimer’s disease and dementia. This is to support staff’s understanding of the needs of some residents at the home. The manager reported that this is due to be undertaken shortly. Although not all residents were able to tell the inspection their experiences of the home, due to their level of need, they were observed looking relaxed and comfortable in their interactions with staff and when eating their meal. Other residents said the following about their life at the home: “very nice and relaxing here” “I prefer it here than in the other home I was in” “I couldn’t be more cared for” “they do everything for you here its lovely” and “nothing is too much trouble”. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, and 11 Resident’s plans of care provide the basic information necessary to guide staff on the needs of residents. The health needs of residents are met, with evidence of regular input from health care professionals. Although medication practices continue to improve, further work is still needed in order to fully safeguard residents. EVIDENCE: Four individual plans of care were inspected. These comprised of many documents including risk and needs assessments, basic information, and a plan of care. These are predominantly standardised forms, which are personalised with the individual’s information, by either ticking the relevant statement or writing brief details. Although plans are basic they provide the essential information to guide staff on the needs of residents. It was previously required that residents be involved in writing and reviewing their care plans. Some residents have signed them to indicate their involvement or that they are aware of its contents. Where residents do not wish to be involved this should be recorded. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 11 Resident’s needs were being reviewed monthly and any changes noted on their care plan. The standard of daily recording was observed to be good with a clear account of actions and events that had occurred. Risk assessments have only been completed when the manager feels that there is a potential risk, for example where a resident has mobility problems. Discussion occurred on the need to risk assess all residents on core/basic risks in order to identify what risk residents face and pose. These should record the actions to manage any identified risks and be reviewed frequently. Several residents said that when they had requested to see their GP this had been organised promptly. Records showed that a chiropodist, district and specialist nurses had recently visited the home. In response to concerns relating to some poor medication practices during the last inspection CSCI’s pharmacy undertook a monitoring visit in the interim period. This showed that standards had improved. Current medication practices at the home, however still require further work to ensure residents are fully safeguarded. This includes ensuring that when staff copy medication instructions onto a resident’s medication record that it is checked and countersigned by another member of staff for accuracy, in order to prevent mistakes. Requirements have previously been made that additional instructions are provided for staff on the administration of “As required” or PRN medication. In order to ensure that staff are fully aware of when to give this medication. Several examples were noted whereby this had not been undertaken and therefore remains a concern. Where improvements have been made to medication practices this has included the development of medication policies and improved recording practices. Resident’s appearance was presented in a manner that preserved their dignity, namely appropriately clothing for weather conditions, which were laundered to a good standard and with regular hairdressing input. Residents said that staff knocked on their bedroom doors before entering. Shared bedrooms are provided with screens in order to promote privacy. The manager spoke of the support they had received in the past from health care professionals during the care of residents who were dying. Staff also spoke sensitively about the care and support provided to residents and their families when residents have become terminally ill. It was previously recommended that staff undergo training in palliative care. The manager reported that staff are undertaking this as part of NVQ training. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Resident’s personal preferences in the daily routines of the home are generally respected with no set times for going to bed and rising. Dietary needs of residents are catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. EVIDENCE: Observation of the daily routines and discussion with residents confirmed that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. Staff are usually employed three afternoons per week to undertake organised activities. However at inspection they were on holiday and the staff on duty were responsible for providing suitable activities, such as bingo and exercise sessions. All residents consulted said that they were suitable occupied, with some preferring their own company and wished to remain in their bedroom. Several residents commented that they missed the activities co-ordinator when she was away, as they enjoyed her company. It was reported that visitors are welcomed at any reasonable time. One resident spoke of how welcome their visitors were made to feel and were always offered a drink. Some residents have a private telephone line in their Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 13 bedroom and they spoke of how this enabled them to keep in regular contact with their relatives and friends. A cook is employed five days a week and in their absence the manager undertakes the cooking. It was previously recommended that the cook undergo training on the nutritional needs of older people, but it was reported this had not yet been undertaken. Residents described the food as: “much nicer these days” “they give me too much I just cant eat it all” “you can have something else if you don’t like what’s on the menu” and “its all very nice”. The meal served at inspection looked appetising and plentiful. Records of meals provided showed that a varied diet was offered with residents individual preferences being catered for. The manager reported that portion sizes have recently been increased. In addition to meals, snacks and drinks are provided, including a fruit bowl, which was displayed for residents to help themselves. One resident was observed being provided with a cold drink as she said that she felt hot and this was obtained for her immediately. The kitchen is small but appeared well organised and clean. It has been required for some time that staff entering the kitchen area must wear protective clothing for the prevention of cross infection. Despite this being made available, not all staff were observed wearing this. The manager was reminded that good infection control standards must be observed. A small laundry store/ironing cupboard is located off the kitchen and the inspector continues to be assured that no dirty laundry is carried through the kitchen area. The dining room forms part of the corridor between the two houses and does not have the capacity to seat all residents at once in comfort. In addition a small dining table has been set up in the lounge. Six residents had chosen to have meals in their bedrooms. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has a satisfactory complaints system in place, with residents feeling able to air any concerns. Adult protection training and procedures have improved since the last inspection. EVIDENCE: There is an accessible complaints procedure for residents, their representatives and staff to follow, should they be unhappy with any aspect of the service. There have been no recorded complaints since the last inspection, and no complaints have been raised with CSCI. Residents consulted said that they felt confident to approach staff or manager with any concerns that they had. There are procedures in place for staff to follow to report suspected abuse. Since the last inspection staff have undergone training in adult protection and prevention of abuse. Staff consulted showed an understanding of their roles and responsibilities under adult protection. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 15 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, 24, 25 and 26 The home promotes a homely atmosphere, and in the main provides a good standard of accommodation. There are a variety of aids and adaptations around the building to assists resident’s independence. Standards of cleanliness were variable. EVIDENCE: The home is located near to Hove high street and is convenient to local amenities such as shops, transports link and the sea front. Communal space consists of a dinning room, main lounge and smaller lounge. These rooms form the corridor in between the two houses and therefore are subject to a lot of through traffic. These rooms are pleasantly decorated with furnishings being domestic in character. There is a small rear garden, which has a raised lawn area, flower beds and some seating. Bedrooms inspected had been personalised by the occupant. A newly admitted resident said that she had been able to bring in some of her own ornaments and now that she is staying longer, intends to bring some of her own furniture. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 16 The standard of cleaning in some bedrooms was noted to be poor, with several residents saying that their bedroom was vacuumed once a week. Discussion took place around increasing the frequency of this. One bedroom had carpet tiles for flooring. Several tiles had become loose and posed a serious trip hazard. The manager was immediate required to rectify this. The curtains in bedroom three had become loose, and needed to be rehung to ensure they provided privacy. Bedroom four was noted not to have any hot water. The manager agreed to arrange for these to be rectified strait away. The home is not registered to offer a service to people with physical disabilities and the access arrangements within the home would make it unsuitable for residents with significant permanent restricted mobility. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including raised toilet seats, walking aids, grab rails and a chair lift. The home has been previously assessed by an occupational therapist who’s report stated that the homes environment meets resident’s functional needs. Although there are adequate number of toilets around in the home, including three bedrooms which have ensuite facilities. Their location often means that one toilet on the ground floor is mainly used during the day, which can result in residents having to wait. There is an assisted bath and a newly installed assisted shower. Suitable locks are fitted to bathroom and toilet doors to provide privacy, but can be overridden by staff in an emergency. The home continues to work hard to manage unpleasant odours, and at inspection this was confined to a couple of bedrooms. Laundry facilities have now been re-located to a recently built shed. This includes the provision of hand washing and appropriate sluicing facilities, in line with previous requirements. Infection control standards have improved in line with previous requirements. This includes the use of red alginate bags to hygienically transport soiled around the home and liquid soap in communal toilets. However some shampoos and bubble baths, belonging to individual residents, remain present in bathrooms in unlocked cupboards and could therefore easily be used for communal use. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 17 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 and 30 There continues to be sufficient numbers of staff on duty to meet the needs of resident’s. Staff training has improved, which has benefited from better planning and resources. EVIDENCE: There is a core group of staff who have worked at the home for a number of years and have considerable experience in caring for older people and who make a positive contribution towards the quality of life of residents. The staffing rota is organised for two care assistants, plus either the manager or senior carer, to be on duty throughout the waking day. This is in addition to a cook and administrator working until early afternoon. Night cover is provided by one staff on waking night duty with the manager providing “on call” off site and within five minutes of the home. This staffing level remains appropriate to meet the needs of current residents, although will need to be reviewed in the light of any new admissions or changes in needs. Domestic staff are employed a few mornings a week with care staff responsible for cleaning in the interim. With variable standards of cleanliness noted the manager identified that domestic hours needed to be increased. Residents described staff as: “very nice” “couldn’t wish for nicer, kinder people” “Most are really helpful” and “they work very hard but are always cheerful” Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 18 None of the current staff have completed an NVQ qualification. The manager stated four staff are due to start this training in the near future. It was reported that no staff have been recruited since the last inspection. At the previous inspection the homes recruitment practices were found to safeguard residents. Much core training has been provided for staff since the last inspection this includes first aid, manual handling, food hygiene, fire safety and adult protection. In line with previous requirements staff training records have been more systematically collated and recorded. Each staff member now has a written profile of the training they have undertaken, enabling any training gaps to be easily identified. Training that remains outstanding include Dementia care and Alzheimer’s, and in the catering needs of older people. The manager reported that this is due to be undertaken shortly. Induction workbooks are used for new employees. This specifies the areas of training to be covered in the initial stages of employment. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 19 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, 32, 35, 36, 37 and 38 A clearer sense of leadership and direction is being provided by the manager who was helpful in their discussions with the inspector. Relationships between residents, staff and the manager were observed to be friendly and informal. The general atmosphere at inspection was relaxed. Although there are some examples of good health and safety practices improvements must be made to meet outstanding concerns relating to fire safety. EVIDENCE: The manager/provider has many years experience in working with older people and reported that she plans to undertake a management qualification in the near future. Since the last inspection the manager has undertaken training in core topics such as adult protection, first aid, food hygiene and infection control. The manager has continued to improve their working knowledge of care legislation. All residents consulted spoke positively about the manager and felt Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 20 at ease to approach her. There is a much clearer sense of leadership and direction provided by the manager, which has enabled residents to receive consistent quality care. Following previous concerns regarding the management of resident’s personal monies the manager has gradually improved the system for managing personal monies including the recording of any resident expenditure. However an example was noted whereby accurate records of hairdressing and chiropody expenditure was not being maintained. The manager and administrator agreed to address this as a priority. Staff said that the manager oversees their work on a daily basis and provides continual support through working directly with staff and residents, but they did not receive formal supervision. There is a need for care staff to receive regular supervision, which covers all aspects of practice, philosophy of care, and career development needs. This is to help underpin the improvements being made to the homes practices. The homes administrator and manager clearly work well together with significant improvements made in the standards of record keeping and general administration at the home. A more organised system of policy and procedure guidance has been implemented to help inform and guide staff in their work with residents. In line with previous recommendations staff now sign to say they have read policies. In addition an employment handbook has been introduced which includes key policies and procedures that can be used as a reference guide. The system for recording accidents has improved, enabling the manager to monitor for any poor standards of recording and patterns of accidents. Previous concerns relating to the delivery of hot water above the recommended temperature range had been addressed and in order to ensure consistent safety standards are maintained it had been required for some time that regular recorded hot water checks be undertaken. The manager reported that the maintenance staff undertake this task weekly but their records could not be located. A fire risk assessment had been undertaken by an external fire safety officer. This had not been reviewed since it had been undertaken twelve months ago, despite changes to the premises namely a new laundry. It is required that the fire risk assessment be reviewed regularly in order to promote good fire safety practices at the home. The inspector continues to express concern regarding a first floor fire exit, which requires residents to climb up and through a fire escape window onto the fire escape. The manager has been required for some time to obtain Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 21 written confirmation from a fire safety expert or fire brigade of the suitability of the fire exits above ground level. This had not yet been fully addressed. It was previously required that regular fire drills be undertaken in order to improve staff and resident’s practical knowledge of the homes fire safety policy. This had not been undertaken and remains outstanding. Continuing failure to meet outstanding requirements in relation to hot water recording and fire safety will now result in legal advice being sought. Some doors have been fitted with acoustically activated door guards to enable them to be left open to aid ease of movement around the home. To address previous concerns relating to residents propping their bedroom doors open with a variety of objects, notices have been displayed reminding residents not to do this. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 2 2 2 STAFFING Standard No Score 27 3 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 x x 2 2 2 1 Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP6 Regulation 13(4)(c) Requirement That comprehensive written personal risk assessments are completed for all service users, which are reviewed regularly and record the actions to manage identified risks. That additional instructions are provided for staff on the administration of “As required” or PRN medication. (First made at inspection of 13/7/03 with timescales of Immediate not met). That hand written Medication Administration Records (MAR) are checked and countersigned by a second member of staff for accuracy. That staff entering the kitchen, and serving food wear suitable protective clothing. (First made at visit of 17/12/04 with timescales of Immediate not met). That carpet tiles in bedroom number six are securely fixed and do not pose a trip hazard. That all parts of the home are kept clean. DS0000014259.V250097.R01.S.doc Timescale for action 30/01/06 2 OP9 13(2) 25/11/05 3 OP9 13(2) 25/11/05 4 OP15 13(3) 25/11/05 5 6 OP24 OP26 13(3)(c) 23(2)(d) 25/11/05 25/11/05 Vallance Rest Home Version 5.0 Page 24 7 OP30 18(1)(c) (i) 8 9 10 OP35 OP36 OP38 17(2) Sch 4 (9)(a) 18(2) 13(4)(c) 11 OP38 23(4)(b) 12 OP38 23(4)(e) & Sch 4 (14) 13 OP38 13(4)(c) That staff receive training in Dementia and Alzheimer’s and a record maintained of this training. (First made at inspection of 15/12/03 with timescales of 30/8/05 not met) That clear and accurate records be maintained of hairdressing and chiropody costs. That care staff receive regular formal recorded supervision. That regular recorded hot water checks be undertaken. (First made at visit of 17/12/04 with timescales of immediate not met). That written confirmation is obtained from a fire safety expert or fire brigade of the suitability of the fire exits above ground level. (First made at inspection of 18/5/04 with timescales of 30/7/05 not met). That fire drills are held a frequent intervals and a record maintained of the outcomes and staff attending. (First made at inspection of 17/7/03 with timescales of immediate not met). That the fire risk assessment be reviewed regularly or when necessary and is recorded as having been reviewed. 28/02/06 25/11/05 30/01/06 25/11/05 30/01/06 25/11/05 30/01/06 Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP15 Good Practice Recommendations That training is provided on the catering needs of older people. Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Vallance Rest Home DS0000014259.V250097.R01.S.doc Version 5.0 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. 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