Inspection on 01/06/07 for Vicarage Court Nursing Home

This inspection was carried out on 1st June 2007.

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

Vicarage Court Nursing Home 10/06/09

Vicarage Court Nursing Home 05/06/08

Vicarage Court Nursing Home 15/09/06

Vicarage Court Nursing Home 30/11/05

Vicarage Court Nursing Home 27/07/05

Vicarage Court Nursing Home 12/01/05

Vicarage Court Nursing Home 07/07/04

Vicarage Court Nursing Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG Lead Inspector Pam Grace Unannounced Inspection 1st June 2007 09:30 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 Vicarage Court Nursing Home DS0000022382.V335700.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. Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vicarage Court Nursing Home Address 160 High Street Chasetown Staffordshire WS7 8XG 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) 01543 685588 01543 677034 morecare@tiscali.co.uk Morecare Limited Vacant Post Care Home 39 Category(ies) of Physical disability (39), Physical disability over registration, with number 65 years of age (39) of places Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability (39) - Minimum age 60 years on admission Date of last inspection Brief Description of the Service: Vicarage Court is a 39 bedded care home with nursing, situated in Chasetown. It comprises of a purpose built building set in a town location, and close to a local shopping centre, and is also on a bus route. The proprietors Morecare Ltd., have run the home since it was first registered in 1995. The home is currently registered to admit 39 elderly service users over the age of 60yrs, and comprises of single and double bedrooms, some of which have en-suite facilities. There are two lounge and dining rooms; other facilities include a hairdressing salon and conservatory. All areas of the home have access to a passenger lift. There are car - parking facilities. At the time of this report the fees were £312.00 minimum up to £567.00 maximum per week. Fees are subject to annual review. Additional charges are made for newspapers, hairdressing, and chiropody. Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was carried out over one day, by one inspector. The inspection had been planned with information gathered from the Commission for Social Care (CSCI) database, and feedback/comment cards received from residents, relatives, GPs and other professionals. There were 8 “Have Your Say” documents received from residents and relatives, and 2 comment cards received from General Practitioners. The key National Minimum Standards (NMS) for Older People were identified for this inspection, and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, residents and visiting relatives. A tour of the environment was also undertaken. The home is currently advertising for the post of Care Manager, which is vacant. There has recently been a Deputy Manager appointed. At the end of the inspection, feedback was given to the home’s Operations Manager – Ms Sharon Banevicius, outlining the overall findings of the inspection, and the requirements and recommendations made. The Statement of Purpose and Service User Guide was not available at the previous inspection, or at this inspection, for the inspector to view. This was because they were both undergoing review. In view of this, the inspector advises that prospective residents should visit the home, and ask relevant questions prior to making any decisions to move into the home. The previous inspection report is available to read in the main entrance hallway of the home. Residents and relatives spoken with, and feedback received, were generally positive about the care that residents and their relatives were receiving. However, feed back documents returned to CSCI from relatives, highlighted some concerns and issues that were discussed with the operations manager during the inspection. These have been highlighted within this report. One complaint had been received by the home since the previous inspection. That complaint was amicably resolved and upheld. There is an activities schedule for residents, and residents enjoy organised trips out with the staff. However, there is only one hour per day provided by staff members to residents in the home for activities. There were 4 requirements, and 4 recommendations made as a result of this unannounced inspection. Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 6 The staff and residents were thanked for their co-operation and open willingness to contribute to the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Staff training must include Fire, and First Aid training. Individual training records for staff must be established. Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 7 A quality assurance system must be established by the home to enable feedback from residents, relatives, representatives, health and other professionals. The home should provide more time for activities for residents. Residents must be consulted as to what recreational activities are on offer. Recreational activities should be tailored to residents’ needs. The Statement of Purpose and Service User Guide must be made available to CSCI, Social Services, prospective residents, and or their relatives/representatives. Residents’ care plans would benefit from the recording of the resident’s social history, i.e. lifestyle, hobbies and interests prior to moving into the home. This would enable a care plan that is more tailored to the resident’s needs. Lounge carpets were stained, and in need of cleaning and or replacing. Some furnishings in the communal areas of the home need replacement. 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. Vicarage Court Nursing Home DS0000022382.V335700.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 Vicarage Court Nursing Home DS0000022382.V335700.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): 1,3,5 and 6 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives do not have the information needed to choose a home that will meet their needs. EVIDENCE: The home is currently recruiting, in order to fill the vacant post of care manager. The home has an operations manager, and a training co-ordinator in post. They are both managing the home at present, with the assistance of a recently appointed deputy manager. The Statement of Purpose and Service User Guide was not available at the previous inspection, or at this inspection, for the inspector to view. This was reportedly because they were undergoing review. It is a requirement of this report that both of these documents are made available to prospective Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 10 residents and their relatives/representatives, as well as to CSCI and to Social Services. The inspector advises that prospective residents should visit the home, and ask relevant questions prior to making any decisions to move into the home. The previous inspection report is available to read in the main entrance hallway of the home. A sample of 5 residents’ care plans were examined. These showed much improvement in that all pre-admission assessments had been reviewed, they were clearer, and were set out in a more structured way, making them easier to read and understand. However, pre-admission assessments need to be more comprehensively completed, to include a social history, and arrangements made in the event of terminal illness. Pre – admission assessments are undertaken either by the deputy manager, or the operations manager, that assessment then forms the basis for the care plan. Residents’ Contracts were not examined at this inspection. However, the operations manager confirmed that all residents have a contract/terms and conditions. Intermediate care is not provided by this home. Vicarage Court Nursing Home DS0000022382.V335700.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, and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: 5 residents’ care plans were randomly sampled and examined. These showed much improvement, in that all pre-admission assessments had been reviewed, they were clearer, and were set out in a more structured way, making them easier to read and understand. Care plans, records and residents spoken with confirmed that residents’ health and personal care needs are being met, records seen showed evidence of GP, and other health professionals’ visits. However, the inspector recommended that residents’ care plans would benefit from a brief social history, containing information about the resident’s hobbies, lifestyle, and social interests. This would enable a care plan, which is more tailored to the residents’ needs. This Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 12 would also be of particular importance in the case of a resident who has a poor short-term memory. The feedback received from “Have Your Say” documents, which CSCI send out to residents and relatives, was mainly positive. However, the inspector discussed specific issues with the operations manager, that were raised within those documents, e.g. moving and handling, bathing, and lost items of clothing. This discussion highlighted the need for a consistent system of recording, so that the right level of support is given by care staff to residents with bathing, and personal care needs. The inspector discussed reimbursing residents and or relatives for lost items of clothing. Service users are protected by the home’s policies and procedures for dealing with medicines. Medication is appropriately stored and administered. The home’s medication fridge had broken, and a new fridge was on order at the time of the inspection. The quality of the food was praised by one resident, and was said to be “unimaginative” by another resident. Menus were examined, and found to be varied, wholesome and nutritious. The home’s high standard of cleanliness was also commented on. Amongst the comments received were “Staff keep me informed of any doctors visits or changes in mom’s condition”. “Any complaints are acted upon”. “The care staff are always very patient with the residents”. Vicarage Court Nursing Home DS0000022382.V335700.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): 12,13,14 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills. However, social educational, cultural and recreational activities are not meeting individual’s expectations. EVIDENCE: Relatives and visitors were seen freely entering and leaving the building. Relatives and residents spoken with very satisfied with the care that they and or their relative received. The inspector noted that the home has an activities calendar. However, residents spoken with said that they were not consulted in regard to what activities are on offer, and there is time for only 1 hour for activities each day, this is usually during the afternoon. This was also confirmed during discussions with staff. The inspector recommended that the home needs an activities coordinator, and more time should be given to organised activities for residents. Care staff run daily activities for residents, dependent upon staffing levels on the day, and their good will. It is also a requirement of this report that residents must be consulted about the programme of activities arranged by or Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 14 on behalf of the care home, and the provision of facilities for recreation, including having regard to the needs of residents, activities in relation to recreation, fitness and training. During a tour of the building, the inspector noted that the kitchen was exceptionally clean. The daily cleaning schedule, hot and cold food temperatures were all appropriately documented and recorded. The 4 weekly rotational menus were wholesome and varied. Special diets are catered for. Residents spoken with, and feedback from comments received said that they were happy with the food provided. Kitchen staff spoken with, and staff training schedule, confirmed that kitchen staff had received appropriate food hygiene updates and training. Vicarage Court Nursing Home DS0000022382.V335700.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 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: The inspector noted that 1 complaint had been received by the home since the previous inspection. That complaint had been dealt with by the operations manager, and had been amicably resolved. No complaints had been received by CSCI since the previous inspection. The inspector discussed the possibility of the Provider reimbursing residents in relation to items of lost clothing. Service users and their families are able to express their concerns and/or complaints. There is a clear complaints procedure on the wall in the main entrance hallway. Staff spoken with, were aware of their right to express their grievances and of the home’s Whistle–blowing procedures. The home has a Protection of Vulnerable Adults (POVA) Safeguarding policy and procedure in place. The operations manager and staff spoken with were Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 16 aware of their responsibilities in regard to the protection of residents from abuse, of all types. The inspector examined 4 staff recruitment files. These are all in the process of being reviewed. Staff spoken with including a new staff member, confirmed that they had undergone appropriate CRB and POVA checks, prior to commencement of employment, and had then received an induction on commencement of employment. The induction had included moving and handling training. Vicarage Court Nursing Home DS0000022382.V335700.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, 21, 23,24,25 and 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, and comfortable environment, which encourages independence. However, some carpets and furnishing need cleaning and or renewing. EVIDENCE: The inspector undertook a tour of the building. 8 new wheelchairs had been purchased since the previous inspection. Wheelchairs in use were seen to be in good and safe order, with appropriate footplates. Communal areas, Bedrooms and bathrooms seen were clean, tidy and adapted to the needs of the residents. However, the lounge carpets were stained, and in need of cleaning. Some furnishings in the communal areas of the home need Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 18 replacement. The home reportedly has a rolling programme of ongoing maintenance. Bathrooms and toilets are suitably equipped and adapted. The domestic services in the home were seen to be of a very high standard, much to the credit of the staff. The home was clean and tidy, with no malodours. The inspector also noted that the kitchen was exceptionally clean. The daily cleaning schedule, hot and cold food temperatures were all appropriately documented and recorded. The 4 weekly rotational menus were wholesome and varied. Special diets are catered for. Residents spoken with, and feedback from comments received said that residents were happy with the food provided. Kitchen staff spoken with, and the staff training schedule, confirmed that kitchen staff had received appropriate food hygiene updates and training. Vicarage Court Nursing Home DS0000022382.V335700.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): 27,28,29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are skilled and in sufficient numbers, to support the people who use the service in line with their terms and conditions, and to support the smooth running of the service. However, staff mandatory training must be kept up to date. EVIDENCE: The inspector examined 3 staff records, and spoke with 5 members of staff, including the home’s training co-ordinator. Records seen reflected a much needed and recent review of all staff recruitment and training files. However, although there has been an improvement in regard to the recording of staff training undertaken, this does not extend to individual staff training records. It is a recommendation of this report that individual staff training records should be established. Kitchen staff spoken with, and records seen confirmed that they had undertaken food hygiene training and updates. Staff spoken with, and records seen confirmed that some staff had not received updated and mandatory training in regard to fire, and first aid training for identified staff had not been undertaken. This was discussed with the Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 20 training co-ordinator during the inspection. It is a requirement of this report that all staff must receive fire training, and identified staff must receive first aid training. There should be at least one staff member qualified in first aid on duty for each shift. Rotas reflected that staffing levels were maintained with the use of bank and or agency staff. The inspector noted that staff recruitment records had been reviewed, and incomplete records had been highlighted and noted. The scoring of 2 for this area reflects that there is still work to be done in relation to recruitment records. Staff spoken with including a new staff member, confirmed that they had undergone appropriate CRB and POVA checks, prior to commencement of employment, and had then received an induction on commencement of employment. The induction had included moving and handling training. There are currently 21 staff undertaking NVQ level 2, and 8 staff undertaking their NVQ level 3 awards. This meets the National Minimum Standard required. There are also 3 qualified nursing staff undertaking their Registered Manager’s Award. Vicarage Court Nursing Home DS0000022382.V335700.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): 31,32,33 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home has been inconsistent due to recruitment difficulties. The home has not got effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The inspector noted that there is a vacant post for care manager at the home, and that there has been a recent appointment of a deputy manager. The operations manager and training co-ordinator are currently managing the home. The Statement of Purpose and Service User Guide was not available at the previous inspection, or at this inspection, for the inspector to view. This was Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 22 reportedly because they were undergoing review. It is a requirement of this report that both of these documents are made available to prospective residents and their relatives/representatives, as well as to CSCI and to Social Services. The feedback received from “Have Your Say” documents, which CSCI send out to residents and relatives, was mainly positive. However, the inspector discussed specific issues with the operations manager, that were raised within those documents, e.g. moving and handling, bathing, and lost items of clothing. Satisfactory responses were received. This discussion highlighted the need for a consistent system of recording. This is to ensure that the right level of support is given to residents with bathing, and personal care. The inspector discussed the possibility of the Provider reimbursing residents in relation to items of lost clothing. There had been one complaint received by the home since the previous inspection. That complaint had been dealt with by the operations manager, and had been amicably resolved. No complaints had been received by CSCI since the previous inspection. Service users are protected by the home’s policies and procedures for dealing with medicines. Medication is appropriately stored and administered. The home’s medication fridge had broken, and a new fridge was on order at the time of the inspection. The inspector noted that staff recruitment records had been reviewed, and incomplete records had been highlighted and noted. The scoring of 2 for this area reflects that there is still work to be done in relation to recruitment records. Staff spoken with, and records seen confirmed that some staff had not received updated and mandatory training in regard to fire, and first aid training for identified staff had not been undertaken. This was discussed with the training co-ordinator during the inspection. It is a requirement of this report that all staff must receive fire training, and identified staff must receive first aid training. There should be at least one staff member qualified in first aid on duty for each shift. Records seen reflected a much needed and recent review of all staff recruitment and training files. However, although there has been an improvement in regard to the recording of staff training undertaken, this does not extend to individual staff training records. It is a recommendation of this report that individual staff training records should be established. The quality of the food was praised by one resident, and was said to be “unimaginative” by another resident. Menus were examined, and found to be varied, wholesome and nutritious. The home’s high standard of cleanliness was also commented on. Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 23 The inspector recommended that the home needs an activities co-ordinator, and more time should be given to organised activities for residents. Care staff run daily activities for residents, dependent upon staffing levels on the day, and their good will. It is also a requirement of this report that residents must be consulted about the programme of activities arranged by or on behalf of the care home, and the provision of facilities for recreation, including having regard to the needs of residents, activities in relation to recreation, fitness and training. Communal areas, Bedrooms and bathrooms seen were clean, tidy and adapted to the needs of the residents. However, the lounge carpets were stained, and in need of cleaning. Some furnishings in the communal areas of the home need replacement. It is a recommendation of this report that stained carpets are either cleaned or replaced, and that old and shabby furnishings are replaced. It is a requirement of this report that the manager must plan and develop a quality assurance system for the service, which allows for feedback into and out of both resident and staff meetings, and for stakeholders’ feedback. The home should also consider relatives’ feedback, and encourage comments from relatives and visitors in relation to the service, e.g. a comment card system. This was discussed with the operations manager. Residents’ finances were not checked during this inspection, these will be monitored at the next inspection. Vicarage Court Nursing Home DS0000022382.V335700.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 X 2 X 3 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 3 17 X 18 3 2 X 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X X X X 3 Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4,16 Sch1, Sch4(1) Requirement The registered person must provide a Statement of Purpose and Service User Guide to the CSCI and shall make a copy of it available on request for inspection by every service user and any representative of a service user. The registered person shall having regard to the size of the care home and the number and needs of service users Residents must be consulted about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including having regard to the needs of service users, activities in relation to recreation, fitness and training. (Previous timescale of 30/01/07 not met) Identified staff must receive mandatory Fire Training, and training in First Aid. (Previous timescale of 31/03/07 not met) DS0000022382.V335700.R01.S.doc Timescale for action 31/08/07 2. OP12 16(2)(m)( n) 30/09/07 3. OP30 18(a) 31/08/07 Vicarage Court Nursing Home Version 5.2 Page 26 4. OP33 24 The registered person must introduce an effective quality assurance system, which is based on seeking the views of residents, relatives and other visitors to the home. (Previous timescale of 31/01/07 not met) 30/09/07 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. Refer to Standard OP7 Good Practice Recommendations Residents’ care plans would benefit from the recording of the resident’s social history, i.e. lifestyle, hobbies and interests prior to moving into the home. This would enable a care plan that is more tailored to the resident’s needs. Residents should have more dedicated time in regard to organised activities provided by the home. The home should ideally employ an activities co-ordinator. Lounge carpets were stained, and in need of cleaning and or replacing. Some furnishings in the communal areas of the home need replacement. Individual staff training records should be established. 2. 3. 4. OP12 OP19 OP30 Vicarage Court Nursing Home DS0000022382.V335700.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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. 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