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Inspection on 15/09/06 for Vicarage Court Nursing Home

Also see our care home review for Vicarage Court Nursing Home for more information

This inspection was carried out on 15th September 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The management and staff make the residents` visitors and relatives welcome, and there are frequent visitors to the home. Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Residents and visiting relatives spoken with confirmed their satisfaction with the services provided at the home. Health care awareness was evident, with the importance of any changes in health status, being continually monitored by appropriately trained, caring and diligent staff. Residents and visiting relatives spoken with confirmed that residents` individual needs and wishes were well met. This was also evidenced by the comprehensive care plans seen. The home`s kitchen was well presented, clean and tidy. Residents spoken with said they were very satisfied with the variety and quality of the food provided at the home.

What has improved since the last inspection?

Ongoing programme of re-decoration for identified bedrooms. The floor in the laundry has been replaced. Replacement paper towel dispensers have been installed throughout the home.

What the care home could do better:

Staff mandatory and update training must include First Aid, Manual Handling, Fire, Food Hygiene and health and safety. Individual training records for staff must be established, as well as a clear training schedule for the coming year.A quality assurance system must be established by the home to enable feedback from residents, relatives, representatives, health and other professionals. Wheelchairs in use by staff, for the transfer of residents, must have appropriate foot rests fitted, in line with health and safety regulations. The white notice board in the main entrance hall should not have inappropriate and personal information written in regard to residents e.g. `feeders`. Information in relation to individual residents should not be on display. Pre-admission assessments seen did not contain enough information, were unsigned, and in some cases undated. Care plans seen were signed, and contained arrangements in the event of terminal illness. However, some care plan reviews were not up to date. There were gaps in regard to staff signatures for the administration of medication, in the Medication Administration Sheets. The inspector noted that wheelchairs used by staff to transfer residents were seen to have no foot - plates in place. It is a requirement of this report that in line with health and safety regulations, wheelchairs must have foot- plates in place when being used by staff for the safe moving or transferring of residents. The registered person must ensure that all staff have undergone an appropriate Criminal Records Bureau check. Staff recruitment records examined showed a lack of evidence of staff identification, and that the appropriate checks had been made, records seen were sometimes unclear, inconsistent, and did not have the required 2 references prior to commencement of employment. It is required that all staff have appropriate identification, 2 references, and CRB checks, and that these are evidenced within staff recruitment records.

CARE HOMES FOR OLDER PEOPLE Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG Lead Inspector Pam Grace Key Unannounced Inspection 15 September 2006 10:00 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 Vicarage Court Nursing Home DS0000022382.V309796.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.V309796.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 Limited 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.V309796.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 30th November 2005 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 £280.00 minimum up to £540.00 maximum. Additional charges are made for newspapers, hairdressing, and chiropody. Vicarage Court Nursing Home DS0000022382.V309796.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 CSCI database, the Pre-Inspection Questionnaire that had been completed by the provider, and feedback/comment cards received from residents, relatives, GPs and other professionals. The key National Minimum Standards 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. At the end of the inspection, feedback was given to the acting care manager, outlining the overall findings of the inspection, and the requirements made. Residents and relatives spoken with were very positive about the care they and their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. Feedback and comment cards returned to the inspector totalled 7 `Have Your Say’ documents, 7 comment cards from relatives, 1 card from a GP, and 1 comment card from other professionals. Feedback and comments received were generally positive, and raised the issues that some relatives were not aware of the home’s complaint procedure, or the inspection report. These were discussed with the acting care manager, and the report/procedure has been placed in a more prominent position in the main hallway entrance to the home. One complaint had been received by CSCI in March 2006. The complaint was not upheld, and some issues highlighted were unresolved. The outcome requirement and 2 recommendations made as a result of that complaint, were monitored during this inspection. The monitoring outcome was satisfactory. The home employs a part time activities co-ordinator at the home. However, although there is a comprehensive activities schedule, and residents enjoy organised trips out with the co-ordinator, there is only one hour per day provided to residents in the home for activities. There were 12 requirements, and no recommendations made as a result of this unannounced inspection these included two immediate requirements which were made in relation to a small number of staff requiring Criminal Records Bureau checks, and the use of wheelchairs by staff, to transfer residents, without the use of foot rests. This was discussed with the care manager and Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 6 the senior care assistant on duty at the time. The administrator confirmed that Staff Criminal Record Bureau Checks had been applied for, however, copies of CRB’s undertaken had not been retained by the individual staff member. This will be reviewed and rectified by the home as soon as possible. The purchase of replacement wheelchairs/foot rests is in progress at the time of this report. 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 mandatory and update training must include First Aid, Manual Handling, Fire, Food Hygiene and health and safety. Individual training records for staff must be established, as well as a clear training schedule for the coming year. Vicarage Court Nursing Home DS0000022382.V309796.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. Wheelchairs in use by staff, for the transfer of residents, must have appropriate foot rests fitted, in line with health and safety regulations. The white notice board in the main entrance hall should not have inappropriate and personal information written in regard to residents e.g. `feeders’. Information in relation to individual residents should not be on display. Pre-admission assessments seen did not contain enough information, were unsigned, and in some cases undated. Care plans seen were signed, and contained arrangements in the event of terminal illness. However, some care plan reviews were not up to date. There were gaps in regard to staff signatures for the administration of medication, in the Medication Administration Sheets. The inspector noted that wheelchairs used by staff to transfer residents were seen to have no foot - plates in place. It is a requirement of this report that in line with health and safety regulations, wheelchairs must have foot- plates in place when being used by staff for the safe moving or transferring of residents. The registered person must ensure that all staff have undergone an appropriate Criminal Records Bureau check. Staff recruitment records examined showed a lack of evidence of staff identification, and that the appropriate checks had been made, records seen were sometimes unclear, inconsistent, and did not have the required 2 references prior to commencement of employment. It is required that all staff have appropriate identification, 2 references, and CRB checks, and that these are evidenced within staff recruitment records. 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. Vicarage Court Nursing Home DS0000022382.V309796.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.V309796.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence, and confirming current practice with the home’s acting care manager, and administrator. Each resident is given a signed contract; following a full pre admission assessment to ensure their needs could be met in the home. Intermediate care is not provided by the home. EVIDENCE: The home’s Statement of Purpose is currently under review. Prospective residents are invited to look around the home prior to making a decision. Residents each have a signed contract/terms and conditions following a preadmission assessment. During discussion with the home’s administrator, it was acknowledged that all prospective residents, relatives, or their representatives receive written confirmation that the home can meet their needs. The home does not provide intermediate care. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 10 A random sample of three individual pre-admission assessments was examined. These formed part of the case tracking process, and identified that pre admission assessments are carried out on all individual residents before they are offered a placement at the home. However, pre-admission assessments seen did not contain enough information, were unsigned, and in some cases undated. It is a requirement of this report that all prospective residents receive a fully documented, signed and dated pre-admission assessment. The previous inspection report is available to read at the home. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 The quality in this outcome area is adequate. This judgement has been made using available evidence, general observation, and discussion with residents and relatives. Care records seen evidenced that residents’ health and personal care needs are being met, however some care plans were not up to date. EVIDENCE: A random sampling of 4 care plans was undertaken. In line with case tracking, residents and staff were spoken with. Appropriate risk assessments were evident in care plans seen. Wound treatment records were clear and up to date, and were cross-referenced with daily records, and the daily diary. Visits by health professionals were also documented. Care records seen evidenced that residents’ health and personal care needs are being met. Care plans seen were signed, and contained arrangements in the event of terminal illness. However, some care plan reviews were not up to date, it is a requirement of this report that these are kept up to date. Service users are protected by the home’s policies and procedures for dealing with medicines. Medication is appropriately stored, however there were gaps in regard to staff signatures for the administration of medication, in the Medication Administration Sheets. These were highlighted by the inspector, Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 12 and discussed with the acting care manager at the time. It is a requirement of this report that all medication administered is signed for, in accordance with the home’s medication policy and procedure. Discussions with these residents and/or their relatives, confirmed the above. All of the residents spoken with said that they were happy with the care they were receiving in the home. Feedback received by the Commission for Social Care Inspection (CSCI), in the form of comment cards, and the `Have Your Say’ document, was generally positive about the services provided by the home. When asked whether dignity and privacy were upheld at the home all of the residents spoken to confirmed this and commented that the staff treated them with `respect’. Vicarage Court Nursing Home DS0000022382.V309796.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 at least once during a 12 month period. 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. The social, spiritual and recreational needs of residents were generally being met at the home, however more input is required for residents’ activities. EVIDENCE: Residents exercise choice and control, and maintain contact with family, friends, their representatives and the local community as they wish. The inspector spoke with the activities co-ordinator, and suggested that activities undertaken by residents should be recorded in a daily diary. The home’s activity co-ordinator confirmed that there are organised trips out for residents, and that staff give their own time to accompanying residents on those trips. However, she also confirmed that there is only one hour per day for organised in house activities for residents at the home. It is a requirement of this report that more hours are provided in regard to activities for residents. Individual spiritual needs were met by regular visits from both the Roman Catholic priest, and the Church of England Vicar. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 14 At the time of this inspection visitors were seen freely entering and leaving the home. Visitors spoken with were not aware of any restrictions placed upon them, apart from the avoidance of visiting during mealtimes. Visitors were able to see a relative in private. Residents were able to bring in small items of furniture and bedrooms were personalised with residents’ possessions. Residents said they had the opportunity and choice to have their hair done, the acting care manager confirmed that some residents at the home were using this service. The quality and choice of meals for residents continue to be satisfactory. The meal of the day was well presented, resident’s comments were positive. Staff were observed taking meals to residents who chose to remain in their rooms, and discreetly assisting some residents with eating and drinking. 4 weekly rotational menus were seen during the inspection of the kitchen, which was notably very clean and tidy. The menus offered a balanced dietary content. The daily cleaning rota for the kitchen was clear, and up to date. Fridge, freezer and food temperatures were documented, recorded and up to date, and food was appropriately and hygienically stored. The home’s use of a white board, in the main entrance hall, on which is written details of the day’s menu for residents, should not be used to display personal details of residents, and what type of diet they are having, e.g. `feeders’ – as in a list of named residents who need assistance with eating and drinking. This was highlighted by the inspector during a tour of the building, and discussed at the time with the acting care manager. Vicarage Court Nursing Home DS0000022382.V309796.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is adequate. This judgement has been made using discussion with staff, and examination of records. Service users and their families are able to express their concerns and/or complaints. Staff were aware of their right to express their grievances and of Whistle–blowing procedures. The home has a Protection of Vulnerable Adults (POVA) policy and procedure in place. The acting care manager and staff spoken with were aware of their responsibilities in regard to the protection of residents from abuse, of all natures. EVIDENCE: There was a clear and accessible complaints and protection of vulnerable adults procedure in place at the home. The inspector discussed the repositioning of the written complaint procedure, as some comments received from residents and visiting relatives, had indicated that they were not aware of the procedure. The home agreed to reposition the procedure, on the outside wall to the acting care manager’s office. The acting care manager stated that she takes all concerns and complaints seriously and addresses them according to the procedure. There had been one complaint about the home received by CSCI in March 2006. Enquiries had been Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 16 subsequently made, and the outcome of that complaint was that the complaint was mostly not upheld, with some aspects of the complaint being unresolved. During the course of this inspection, the inspector undertook monitoring in relation to the requirement and recommendations made in regard to the outcome of that complaint, with a satisfactory outcome. Residents and relatives spoken with, confirmed that they would know who to approach should they have any concerns or complaints. Staff spoken with confirmed that they were aware of the need to monitor the safety of residents and to protect them from any form of abuse. Vicarage Court Nursing Home DS0000022382.V309796.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for its stated purpose. Service users live in a safe, clean and comfortable environment, which has been adapted to suit their lifestyle, and individual needs. EVIDENCE: The inspector undertook a tour of the home, which included all the communal areas. The home was found to be clean and well presented throughout. Bedrooms had been adapted to suit the needs of the service users and there was evidence of personal effects in bedrooms. Some bedrooms seen were in need of re-decoration and /or refurbishment. This was highlighted and discussed at the time with the acting care manager. A list of bedrooms requiring re-decoration will be forwarded to the Provider. This will be monitored at the next inspection. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 18 The manager confirmed that the home has a new maintenance person, and that the home has an ongoing programme of maintenance, redecoration and refurbishment. 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 noted that wheelchairs used by staff to transfer residents were seen to have no foot - plates in place. It is a requirement of this report that in line with health and safety regulations, wheelchairs must have foot- plates in place when being used by staff for the safe moving or transferring of residents. Vicarage Court Nursing Home DS0000022382.V309796.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is poor. This judgement has been made using discussion with the acting care manager and staff, examination of the staff rota, and pre-inspection documentation. Staff must be trained in order to competently do their jobs. The home must review their recruitment policy and practices. EVIDENCE: The acting Care Manager confirmed that the home’s overall staffing coverage has improved, and the use of agency staff has been considerably less than at the time of the previous inspection. The inspector spoke with staff members. Staff spoken with confirmed that they had not received mandatory training, i.e. fire training updates, POVA, moving and handling, health and safety. Staff must receive appropriate training in regard to their role and responsibilities, this must include up to date Fire training, POVA, and moving and handling training. All staff must have a minimum of 3 paid days training per year, (including in house training), and have an individual training and development assessment and profile. Staff spoken with confirmed that they had attended various appropriate courses. However, records seen confirmed that some care staff would receive Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 20 the minimum of 3 days paid training per year, and others would not meet that target. It is a requirement of this report that all staff should receive a minimum of 3 paid days training per year. It is also requirement of this report that all kitchen staff must receive appropriate food hygiene training. Staffing levels were seen to be appropriate to the number of service users in residence at the home. The acting care manager confirmed that existing staff members try to cover shifts that other staff would be unable to undertake, due to sickness or holidays. The home employs a full time administrator – shared with the sister home, and a part time gardener/maintenance person. The acting care manager confirmed that she and a colleague had just undertaken and achieved the First Aid Appointed Person – 1 day course. It is a requirement of this report that the home must provide a member of staff qualified in First Aid for each shift. This must be a full First Aid Certificate, and not just an Appointed Person Certificate. The acting care manager is in the process of applying to the Commission for Social Care Inspection (CSCI) in regard to Care Manager Registration. The home does not currently have a full and clear staff training schedule for the coming year, and individual training records for staff are not yet implemented. The inspector requested that a copy of the home’s staff training schedule, and individual staff training records is forwarded to CSCI. The inspector spoke with staff, and examined staff recruitment records. Acting upon information gathered from the pre-inspection documentation, and discussion with the acting care manager during the inspection, the inspector contacted the administrator in regard to CRB checks for some existing staff members. It is a requirement of this report that all staff have undergone appropriate Criminal Record Bureau checks, and that these are documented and evidenced by the registered person. Staff recruitment records evidenced that although there is a recruitment system in place, some records seen were not clear and consistent, and did not contain 2 references or appropriate identification. It is a requirement of this report that recruitment records must show appropriate identification of the staff member, i.e. copy driving license, passport, proof of address, and that 2 references have been obtained prior to commencement of employment. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 21 Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36 and 38 Quality in this outcome area was poor. This judgement has been made using discussion with the acting care manager, residents, relatives and staff, examination of records, pre-inspection documentation, feedback received from comment cards, and direct observation. The acting care manager is yet to be registered with the CSCI. Several issues have been highlighted as a result of this inspection relating to care planning, health and safety, activities for residents, staff training and recruitment, and quality assurance. Requirements have been made in those areas. EVIDENCE: The acting care manager has been in post since April 2006, and knows the home well. She is a qualified RGN, (having previously worked at the home) however, she had not experienced an inspection in her current role, prior to this one, and she is not yet registered with CSCI. This was discussed at the Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 23 time of the inspection, and it is anticipated that she will make an application to CSCI within the next few weeks. The inspector discussed concerns in relation to staff training, which had been a previous requirement, and which was outstanding from the previous inspection. The acting care manager is aware of the need to promote staff training, and is pro-actively seeking appropriate courses for staff to undertake. She is aware of the urgent need to clearly establish a training schedule and individual training records for staff. The inspector requested an update in relation to how many care staff had undertaken their NVQ level 2/3 awards. Staff spoken with confirmed that they had not received mandatory and update training in the following areas, first aid, manual handling, fire, food hygiene, health and safety. A training schedule for the coming year, and individual training records for staff must be established. A quality assurance system has not been established by the home. This would enable feedback from residents, relatives, representatives, health and other professionals. It is a requirement of this report that a system for promoting quality assurance is implemented by the home. The inspector examined staff recruitment records. The registered person must ensure that all staff have undergone an appropriate Criminal Records Bureau check. Staff recruitment records examined showed a lack of evidence of staff identification, and for some staff did not evidence that the appropriate checks had been made, records seen were sometimes unclear, inconsistent, and did not have the required 2 references prior to commencement of employment. It is required that all staff have appropriate identification, 2 references, and CRB checks, and that these are evidenced within staff recruitment records. The inspector discussed staff supervision with the acting care manager, and with care staff. Staff supervision is in the planning stage, and is about to be implemented. This will be monitored at the next inspection. The inspector toured the building, and noted that staff were using wheelchairs for transferring residents, without appropriate foot plates. It is required that wheelchairs in use by staff, for the transfer of residents, must have appropriate foot rests fitted, in line with health and safety regulations. The inspector noted the inappropriate use of written information on the white notice board in the main entrance of the home. The white notice board in the main entrance hall should not have personal information written in regard to residents e.g. `feeders’. Information in relation to individual residents should not be on display. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 24 Pre-admission assessments seen showed an inconsistent approach, with poor gathering of information which was unsigned and undated. It is required that pre-admission assessments must be fully completed, are signed and dated by the staff member undertaking the assessment. Care plans seen were signed, and contained arrangements in the event of terminal illness. However, some care plan reviews were not up to date. It is required that care plans are reviewed on a monthly basis. Reviews must be documented and recorded. The inspector examined MAR sheets in relation to the administration of medication. There were gaps noted by the inspector in regard to staff signatures in the Medication Administration Sheets. It is required that all medication administered must be signed for. The pre-inspection questionnaire completed by the acting care manager confirmed that appropriate policies and procedures were in place, and that checks and tests in relation to Hoists, Fire Safety, water temperatures, heating and lighting, had been undertaken and were up to date. A random spot check was undertaken by the inspector in regard to residents’ finances, the amounts checked, tallied with records held. Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 3 X 2 Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation Requirement Timescale for action 15/09/06 2. 3. 4. OP7 OP9 OP12 14Sch3(1) New service users are admitted (a) only on the basis of a full assessment, undertaken by people trained to do so. 15Sch3(1) Care plans should be reviewed (b) monthly. 13(2),Sch Staff administering medication 3(3)(1) must sign the Medication Administration Record. 16(2)(m) The registered person shall (n) 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. 13(1)(c) 19(1)(b) (i) 15/09/06 15/09/06 30/01/07 5. 6. OP22 OP29 Wheelchairs must have foot 15/09/06 plates in place when being used to transfer or move residents. CRB checks must be documented 15/09/06 and evidenced for all staff working at the home. DS0000022382.V309796.R01.S.doc Version 5.2 Page 27 Vicarage Court Nursing Home 7. OP29 19(4)(b) 8. OP30 18(a) Staff records must contain appropriate identification and 2 references, as per paragraphs 1 to 7 of Schedule 2 of the National Minimum Standards (NMS). Staff must receive a minimum of 3 paid days training per year. (Previous timescale of 31/03/06 not met) The cooks and kitchen staff must receive appropriate training and updates in food hygiene. (Previous timescale 31/03/06 not met) Staff must receive mandatory training, in respect of Fire Training updates, moving and handling, and health and safety. Staff must receive First Aid training. There must be a qualified First Aider – Full First Aid Certificate holder, on each shift worked. 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. 15/09/06 30/09/07 9. OP30 18(a) 31/03/07 10. OP30 18(a) 31/01/07 11. OP30 18(a) 31/03/07 12. OP33 24 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vicarage Court Nursing Home DS0000022382.V309796.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Vicarage Court Nursing Home DS0000022382.V309796.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. 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