Inspection on 04/12/06 for Vaughan Lee House

This inspection was carried out on 4th December 2006.

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 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

Vaughan Lee House 23/07/08

Vaughan Lee House 16/01/08

Vaughan Lee House 09/02/06

Vaughan Lee House 08/08/05

Vaughan Lee House 04/02/05

Vaughan Lee House 16/09/04

Vaughan Lee House 25/03/04

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 Vaughan Lee House Orchard Vale Ilminster Somerset TA19 0EX Lead Inspector Ms Sue Hale Unannounced Inspection 4th December 2006 09:00 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 Vaughan Lee House DS0000016070.V320993.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. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vaughan Lee House Address Orchard Vale Ilminster Somerset TA19 0EX 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) 01460 52077 vaughanleehouse@tiscali.co.uk ILMINSTER AND DISTRICT (O P W) HOUSING SOCIETY Limited Mrs Rosalind Anne Woolmington Yvonne Foulsham Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 Brief Description of the Service: Vaughan Lee House is a care home providing care and support for up to 26 older people. The home is located in a residential area of Ilminster. Local services including shops, pubs and public transport are nearby. The home is owned and managed by a local charitable organisation. The home was purpose built in 1970 with the specific aim of providing support for local people. Consequently the majority of residents are from Ilminster and the surrounding villages. Locally based staff are also attracted to working in the home. Consequently the home has strong links with the local community that benefits the residents. All accommodation is on the ground floor and bedrooms are for single occupancy. The home offers a limited amount of day care for non-residents each week. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first key inspection of Vaughan Lee House using the Inspecting for Better Lives methodology introduced by the Commission for Social Care Inspection in April 2006. The inspection methodology used by the Commission for Social Care Inspection enables the inspector to make a judgement on the quality of the service delivery based on the outcomes for residents. The inspector looked at selected staff and residents personal files and checked documentation related to the running of the home such as policies and procedures. The inspector undertook a tour of the premises and viewed a selection of residents’ private rooms and all the communal areas. As part of the inspection process surveys were sent out to some staff, residents, medical, health care and social care professionals. The responses have been collated and these and any individual comments are incorporated into this report. The current fees are from £361 to £474 per week. What the service does well: The statement of purpose contains good detail on how the home will promote individuals right to privacy and dignity and makes clear the homes ethos of encouraging and supporting independence. A working care plan is kept in residents’ rooms so that they are able to view it at any time. Staff support and encourage residents to access all neceary health and medical care. Residents really enjoy the monthly trips out of the home to local places of interest. Residents were aware of their right to raise any concerns or complaints and were confident that these would be listened to and dealt with appropriately. Two residents told the inspector that its ’lovely here, staff are very helpful’. Staff were seen to encourage independence but offer discreet assistance when need. The food served at Vaughan Lee is home made and provides a good standard of nutrition for residents. Staff are familiar with individuals likes and dislikes and make good efforts to suit individuals preferences. The majority of the staff is qualified to NVQ level 2 or above which means that they have the skills and experience to provide a good standard of care. One Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 6 medical professional commented that the home was ‘efficiently run and was confident that the ‘staff provided an excellent standard of care’. Residents confirmed that they were treated with respect by staff and their right to privacy and dignity was respected. The home uses the common induction standards for all new staff. A comment made by a medical professional who visits the home was that Vaughan Lee environment was always clean and that the home had a ‘friendly and welcoming atmosphere’. The home was clean, tidy and free from odours on the day the inspection. Residents are satisfied with the laundry service of the home provides. Infection control policies, procedures and practice safeguard residents and staff. All accidents are recorded and a letter is sent to individual residents G.Ps informing them of any falls or accidents. Records were stored securely. Health and safety is taken seriously to safeguard residents and staff. What has improved since the last inspection? What they could do better: The statement of purpose must be reviewed and updated to reflect the current situation at the home and include all the information required in the Care Home Regulations 2001. The terms of conditions of residency need to be revised to include all the information required in the Care Home Regulations 2001. Serious consideration should be given to employing a designated activities organiser to make sure that residents are provided with a range of activities suitable to their needs and preferences. Consultation with residents about what they would like to be available should take place. The home would benefit from redecoration, refurbishment and updating of the communal areas and some residents private rooms. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 7 Serious consideration should be given to increasing the number of care staff during the day and increasing the number of waking night staff to two to make sure that residents needs can be met in a timely person centred manner. The home have been asked to provide evidence of how the current staffing levels during the day and night meet the identified needs of the number of residents cared for both permanently and those who attend for day care. One resident said that ‘staff are always busy and we have to wait’. Serious consideration should be given to increasing the time allocated to the registered manager and her deputies to effectively undertake management duties rather than working as carers. This would enable issues such as policies, procedures, care planning and assessments to be more effectively managed. Polices and procedures need to be reviewed and updated if necessary to reflect current good practice advice and the national minimum standards. All records should be maintained in a manner that complies with the Data Protection Act 1998. Improvements are needed in the management of residents’ finances to safeguard their interests. Quality assurance systems must be set up to review and improved the quality of care provided at the home. This must include residents and their relatives/represntives and should also include other stakeholders. 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 summary of this inspection report can be made available in other formats on request. Vaughan Lee House DS0000016070.V320993.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 Vaughan Lee House DS0000016070.V320993.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3. Standard 6 is not applicable to this service. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose sets out the ethos of the home but does not include all the information required. All residents are given a terms and conditions of residency this needs revision to meet the national minimum standards. Residents’ needs are not fully assessed before they move into the home. EVIDENCE: The home has a statement of purpose dated 2001. It contains good detail about the homes ethos and how it intends to respect individuals right to privacy and dignity. However, it needs significant updating and reviewing to Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 10 meet the national minimum standards. A service user guide was requested but not received at the time of writing this report. The home has a statement of terms and conditions that is given to all residents to tell them about the terms of their residency at the home. The Inspector looked at the personal files of the three people whove moved into the home since the last inspection. There was no evidence that pre admission assessments had taken place to make sure that the home could meet individuals health, social and care needs before residents moved in. The assistant head of home was advised that pre assessments should cover all the topics detailed in standard 3.3 of the national minimum standards. All admissions are on a four-week trial basis after which the placement is reviewed to make sure that the home can meet individuals needs and that residents are satisfied with the care they receive. Prospective residents and their relatives are encouraged to visit the home and spend time there before making a decision on residency. Vaughan Lee House DS0000016070.V320993.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are clearly written and give clear advice to staff on how to met residents’ needs. Risk assessments are not undertaken routinely. Residents are treated with respect and their right to privacy and dignity is maintained. EVIDENCE: Care plans are kept in the office and also in the residents’ rooms. They generally held up to date relevant information and overall care is reviewed each month, rather than each element of the care plans. The assistant managers spoken to had a very good understanding of the residents’ individual needs. The home does not undertake falls or nutritional risk assessments as routine and not all files contained a moving and handling risk assessment. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 12 However, the inspector spoke to the cook and systems were in place to monitor the nutrional intake of residents and steps taken if any concerns are raised about individuals’ nutritional intake. On one care file checked several documents were blank including the assessment and care plan. It was noted that not all documentation on care files was dated or signed. It was evident that residents are supported and encouraged to access health, medical and any other services such as optician, dentists, and chiropodist as needed. A district nurse visiting the home on the day of the inspection spoke very highly about the care residents receive. They told the inspector that referrals were always appropriate and made in a timely manner. The inspector was told that staff always follows healthcare advice given and contact the nursing team for advice and support. Pressure relieving equipment is provided after referral and assessment by the district nursing team. The inspector observed that staff were friendly and professional towards residents and treated them with respect. Residents spoken to confirmed that this always happened and that staff knocked on the door pf their private room before entering. The induction training for staff gives clear guidance on how care should be provided to maintain individuals rights to privacy and dignity. Residents who have the capacity are encouraged and supported to manage their own medicines within a risk assessment that is reviewed regularly. Appropriate lockable storage facilities are provided in individuals’ private rooms. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received administered and disposed of are recorded. The home has a drugs fridge and the temperatures are recorded. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The allocation of staff time for activities is insufficient for the number of residents living at the home and attending for day care. Visitors to the home are encouraged and made welcome. Residents are satisfied with the standard and variety of food served. EVIDENCE: The statement of purpose states that a’ wide range of leisure activities’ is available for residents to choose from. However, the staff time allotted for activities is one hour per day for all residents and the additional people who go to the home for day care. There are monthly trips out of the home and residents spoken to were very positive about these and told the inspector that they were always looked forward to. Some residents told the inspector that they would like to be able to go out into Illminster but that they could not do so without staff assistance and there were not enough staff to do this. Some residents were satisfied with the level of activities on offer. One relative Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 14 commented that they always enjoyed going to social events arranged at the home and said that ‘the place is very friendly’. The routines of the home are as flexible as possible to meet the residents’ needs and preferences. Resident spoken to confirmed that they were able to get and go to bed at times to suit them. Residents also told the inspector that their families and friends were encouraged to visits and were made welcome at the home. People living at the home are able to continue with the religious observance of their choice by contact with visiting clergy. A copy of the residents care plan is kept in their private rooms and they are able to look at this and make comment on it to staff at any time. An Age Concern information leaflet is on display in the entrance hall. The home has an advocacy policy that concentrates on self-advocacy by residents and does not make clear residents rights to access external advocacy agencies. The cook told the inspector that there is a 12-week rotating menu, and that there is a summer and a winter menu. There isn’t a planned choice at lunchtime although residents are able to have an alternative if they don’t like the main course. The cook said she meets with all new residents to find out their likes and dislikes and there was a notice in the kitchen so that all staff was aware. All the residents spoken to on the day of the inspection were very satisfied with the quality and variety of food served at the home. Tables were laid with cloth and cloth napkins with condiments available. The cook had obtained the CSCI guidance on nutrition and older people and was planning to check this document and make any changes necessary to the menu or type of food served. Residents told the inspector that they could choose to have a cooked breakfast if they wanted to. Lunch on the day of the inspection was home made chicken pie and rice pudding, with alternatives available. The inspector noted that water was provided with the lunchtime meal, this was in plastic measuring jugs. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were clear they could raise any concerns and confident that they would be taken seriously. Complaints policies and procedures need reviewing to meet the national minimum standards. Polices and procedures were in place to protect vulnerable adults but need updating to reflect current good practice advice. EVIDENCE: The home nor the CSCI received any complaints since the last inspection. All the residents spoken to are clear about whom to talk to if they had a complaint to a concern and were confident that it would be sorted out. The home has a complaints policy but that didnt include a timescale within which complaints would be investigated and did not make clear the complainants are able to contact the CSCI at any stage for complaint. The home has a whistle blowing policy that is displayed in a public area of the home; this includes the CSCI and Age Concern details, but not Public Concern at Work contact details. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 16 The management of violence policy was not person centred and did not reflect that physical or verbal aggression by residents may be due to temporary or permanent confusion. The home had two lots of information available about adult abuse. The information available to staff in the policies and procedures file was dated 2000 and did not reflect current good practice advice. The home has a finance policy that makes clear that staff are not allowed to accept gifts from residents but it does not include guidance for staff that they should not assist with or benefit from residents on wills. However, this is made clear in staff contracts of employment. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy; the home has a programme of ongoing refurbishment, redecoration and updating. Residents are satisfied that the laundry service provided by the home. Infection control policies and procedures are in place to safeguard residents and staff. EVIDENCE: The home was clean and tidy on the day of the inspection. The inspector looked around the home and viewed some of the residents’ private rooms. All rooms were well looked after, clean and tidy. Residents are able to personalise their rooms according to their own taste and brings in small items of furniture Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 18 within the space constraints. Residents do not have access to a lockable space to store their valuables within their room although they are able to have a key to their room and keep it locked if they want to. It was noted that one resident’s room had recently been redecorated, refurbished and updated and this was done to a good standard. The resident occupying the room was very pleased with the standard of accommodation they had been offered. One bathroom was currently being refurbished and this was also being updated to a good standard. Staff try hard to provide a homely atmosphere. However, some of the furniture and fittings throughout the home are tired and worn through wear and tear. Some items, including carpets need replacement. The inspector was told that there was a planned programme of refurbishment due to take place once the additional rooms and building work was finished. The home has recently fitted a new sluice room. The door to this was not locked. The residents spoken to were very satisfied with the standard of the laundry service and said that their clothes were well cared for by staff and returned in good time. The laundry has hand washing facilities available and the floor was non permeable. Protective clothing and gloves were readily available for staff. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of care staff is qualified to NVQ level 2 or above. Staffing levels did not appear sufficient to meet residents’ needs. EVIDENCE: The home employs 16 care staff, 66 of which are qualified to NVQ level 2 or above. One residents surveyed said that ‘I have always had immediate attention when required’. However, four residents surveyed said that there was only usually staff available to assist them if necessary. Several residents spoken to during the inspection were very positive about the staff and how hard they worked but were clear that they sometimes had to wait for staff attention, as they were so busy. It was clear from observation on the day of the inspection that staff were working very hard but were totally task orientated and they were not able to spend time with the residents once tasks were completed. The home has one waking night staff and one sleeping in. As the dependency of the residents has increased this number does not appear to be sufficient to meet residents needs. Staff and residents told the inspector that the person ‘sleeping’ was frequently awake and working. This meant that they were awake and working during the night and then during the following day. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 20 The staff files of some new members of staff were checked. All contained application forms. Whilst the application form included a health declaration and information about the Rehabilitation of Offenders Act it requires revision to make sure it complies with equal opportunity employment legislation. It was positive to see a record was kept of applicants’ interviews. All staff is given terms and conditions of employment and a job description. The deputy head of home told the inspector that it was proving difficult to get copies of the General Social Care Council code of conduct but efforts to do so would continue. None of the files contained a photograph of the member of staff and there was no evidence that photographic evidence of identity had been seen prior to them starting work. All new staff work shadow shifts as part of their induction, and complete an indication programme and the home uses the common induction standards as recommended in the national minimum standards. Staff are encouraged to attend training but although the home pays the course fees of external training, they are not paid to attend. A training matrix was requested but not received at the time of writing this report. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Ms Foulsham has the skills and experience to manage the home effectively, but this is limited by the number of hours available as supernumerary to the care rota. Quality assurance monitoring is not regarded or implemented as a care management tool. Management of residents’ personal finances need to improve significantly to safeguard residents. Health and safety is taken seriously to safeguard residents and staff. EVIDENCE: Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 22 All residents spoken to were very positive about the registered manager and the deputy heads of home. Staff were also very positive about the encouragement and support that was available and told the inspector that the manager was always available for support and advice. Ms Foulsham has achieved NVQ level 4 in care and the NVQ level 4 registered managers award. Regular staff meetings are held with all staff with minutes taken and copies available to staff. The registered manager is expected to work as part of the care team for the majority of her working time and the time allocated to manage the home is only 46.5 hours over a four-week period. The deputy managers are also expected to work as care staff and also undertake some domestic duties such as washing up at weekends. An accident book is completed when necessary and a letter sent to individuals G.Ps if a fall occurs or if they sustain an injury. The inspector was told that the home did not undertake formal quality audits with residents or other stakeholders such as medical and healthcare professionals who visit the home. Residents’ views were said to be sought informally but there was no evidence to support this. Staff meetings are held throughout the year and staff told the inspector that they are able to voice their opinions at these meetings. Records were stored securely but as detailed elsewhere in this report many policies and procedures are dated 2002 and there was no evidence of review to make sure these were still relevant and contained up to date guidance and good practice advice for staff. Advice should be sought on whether the way in which the communication book is used by night staff to record care issues is compliant with data protection legislation. Staff told the inspector that information was later transferred to the individuals care file but time constraints due to pressure of work during the night shift did not allow individual entries to be made at the time they occurred. Residents are able to manage their own finances for as long as they are able. The home holds personal allowances for some residents; these were all recorded in one bound book. Staff signatures were not recorded when transactions took place and receipts were not kept securely to aid auditing. The records of three residents whose care files had been checked were looked at, one was seen to be correct, two did not contain the correct amount of money detailed on the record. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 23 Appropriate records were kept in the kitchen of fridge and freezer temperatures and safeguards are in place in relation to the preparation, serving and storage of food to ensure the health and safety of residents. Records were seen that demonstrated that the equipment in the home was being maintained and serviced regularly. The home does not have any standing water so the risk of legionella is reduced. Vaughan Lee House DS0000016070.V320993.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 2 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X 2 X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Vaughan Lee House DS0000016070.V320993.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 OP1 Regulation Schedule 1, 4 (1) (c) Requirement Timescale for action 30/04/07 2 OP2 Schedule 4 (8) The statement of purpose must be reviewed and updated to include all the information required in the Care Home Regulations 2001. (This refers to the number, relevant qualifications and experience of staff working at the home, the relevant qualifications and experience of the registered provider and any registered manager, the size of rooms in the care home, the age range and sex of the service users that can be accommodated at the home, a range of needs that the care home is intended to meet, whether nursing is to be provided, the specific details of the complaints policy). The statement of terms and 30/04/07 conditions must be revised to include all the information required in the Care home regulations 2001. (This refers to a record of the charges to residents, including any extra amounts payable for additional services not covered by those charges and the amounts paid by DS0000016070.V320993.R01.S.doc Version 5.2 Vaughan Lee House Page 26 3 OP16 22 (4) 4 OP29 5 OP27 Schedule 2(1) 10(1)(b)(i ) 18(1)(a) 6 OP33 24(1)(3) or in respect of each resident). The registered person must make sure that the complaints policy includes a timescale of 28 day within which complaints will be investigated. The registered person must that photographic evidence of identity is sought and retained on staff files. The registered person must ensure that staff are available in sufficient numbers as appropriate for the health and welfare of the service users. (This refers to day and night staff). The registered person must ensure that arrangements are put in place in relation to quality assurance systems. This must include residents and their representatives. 30/04/07 30/03/07 30/03/07 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations The statement of purpose should include specific details of the homes complaints policy and procedure including timescales and CSCI contact details. The statement of terms and conditions should be revised and include the room to be occupied, the fees payable and by whom, the rights and obligations of the residents and registered provider and who is liable if there is a breach of contract, the terms and conditions of occupancy, including period of notice. Falls and nutritional risk assessments should be undertaken on admission and as necessary thereafter. It is strongly recommend that a designated activities organiser be employed. DS0000016070.V320993.R01.S.doc Version 5.2 Page 27 3 4 OP8 OP12 Vaughan Lee House 5 6 7 OP14 OP15 OP16 8 9 10 OP18 OP18 OP18 11 12 13 OP26 OP29 OP35 14 OP31 The advocacy policy should make clear the residents have the right to access external advocacy services contact details of which should be included. Consideration should be given to providing more suitable jugs for residents use at mealtimes. The complaints policy should be reviewed to made clear the complainants of able to contact the CSCI at any stage for complaint. This should be reviewed in the statement of purpose, service user guide and statement of terms and conditions. The whistle blowing policy should include the contact details of Public Concern at Work. The management of violence policy should be reviewed and updated to reflect current good practice advice and guidance. Information available to staff on adult abuse/protection should be consistent and reflect up to date good practice advice. It should include the contact details of the local vulnerable lead in Social Services. The door to the sluice should be kept locked at all times. The registered person should ensure that the staff applications form complies with employment legislation. The registered manager should ensure that two staff signatures are recorded for all residents’ personal financial transactions. The records should be kept in a manner that complies with the Data Protection Act 1998. Receipts should be kept securely and accounts should be regularly audited and checked. Urgent consideration should be given to increasing the time allocated for the registered manager to undertake management duties. Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Vaughan Lee House DS0000016070.V320993.R01.S.doc Version 5.2 Page 29 - 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. 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