Inspection on 22/05/06 for Vicarage Farm Nursing Home

This inspection was carried out on 22nd May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Vicarage Farm Nursing Home 28/04/08

Vicarage Farm Nursing Home 21/08/07

Vicarage Farm Nursing Home 19/10/06

Vicarage Farm Nursing Home 16/11/05

Vicarage Farm Nursing Home 20/04/05

Vicarage Farm Nursing Home 16/12/04

Vicarage Farm Nursing Home 08/06/04

Vicarage Farm Nursing Home 17/02/04

Vicarage Farm Nursing Home 07/10/03

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

CARE HOMES FOR OLDER PEOPLE Vicarage Farm Nursing Home 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 22nd May 2006 09.45 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 Farm Nursing Home DS0000010962.V295968.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 Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vicarage Farm Nursing Home Address 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA 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) 020 8577 4000 020 8572 1221 vicaragefarm@schealthcare.co.uk Southern Cross Healthcare (Management) Limited Mrs Marilyn Roque Care Home 62 Category(ies) of Dementia (0), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (0), Physical disability over 65 years of age (0) Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 35 mentally ill 27 elderly medically frail 5 patients with mental illness over the age of 50 (included in the total of 35) 16th November 2005 Date of last inspection Brief Description of the Service: The home is situated in a residential area of Hounslow. It is set back from the road and has good car parking facilities. There are local shops within walking distance. There are accessible local bus routes and the home is within ten minutes walk of Hounslow West underground station. The home is set on two floors. The ground floor provides accommodation for twenty-seven service users and the first floor provides accommodation for thirty-five service users. The home provides nursing care to older people with a range of care needs to include dementia, mental disorder and physical disability. There are fifty-four single rooms and four shared rooms in the home. There is a well-maintained central courtyard area with furniture suitable for service users and their visitors. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 22 hours was spent on the inspection process. One Inspector carried out a tour of the home, and a selection of service user plans, staff records, and maintenance & servicing records were viewed. The CSCI Pharmacy Inspector carried out an inspection on 23/05/06. 8 service users, 7 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire, given to the home at the time of inspection, was also used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls with some areas of the service user plans were identified. One area related to this was reported as the lack of time available to complete the paperwork satisfactorily. Although medications are generally being well managed, some shortfalls have been identified and need addressing. Staffing shortages were identified and this has also had an impact on the number of falls recorded, especially during the afternoon on the first floor unit. The staffing levels need to be reviewed in line with service users dependencies, and an immediate requirement was set in respect of staffing. Several shortfalls were identified with the environment, and some areas of the home are institutional in appearance. A full audit needs to be carried out and a redecoration and refurbishment programme with timescales for completion drawn up as a matter of priority. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to admission to ensure the home can meet their needs. Staff have the training and skills to meet any specialist needs of service users. Pre-admission visits are encouraged in order to ascertain if the home is able to meet the prospective service users needs and to give them informed choice. EVIDENCE: Samples of pre-admission assessments were viewed and these were comprehensive and gave a good picture of the service users assessed needs. Copies of the Social Services needs led assessments were also available in the files viewed. Where a service user has physical nursing needs and may also have early onset dementia, placement within the home is made on the ground floor according to their physical need. The Registered Manager said that the fact that in time it may be necessary to transfer the service user to the first floor mental health and dementia care unit is discussed at the time of admission and agreed in writing. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 9 Some of the service users are from minority ethnic groups, and staff were heard communicating with these service users in their own language. Service users were dressed appropriately, in line with their cultural needs. Improvements have been made to the menu to include an Asian meal option at lunch and supper times. On the first floor there is a registered nurse with a mental health or dementia care qualification on duty on each shift. Photographs on display of various religious festivals celebrated by the home showed evidence of ethnic diversity. Relatives spoken with said that they had been able to visit the home prior to the service users moving in. They had also been given information regarding the services and facilities provided by the home. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The service user plans are generally well formulated and updates were not taking place regularly. Information required by staff to meet the service users needs was not up to date. Staff are courteous to service users and personal support is provided in such a way as to promote and protect the service users privacy, dignity and independence. EVIDENCE: Service user plans were sampled on each floor. Generally these were up to date and reflected the service users needs. There was evidence of monthly updates, and new care plans had been formulated for any newly identified needs. The home now has a ‘resident of the day’ on each floor, and as part of their care for that day, the service user plan is reviewed and updated as necessary, thus ensuring that all service user plans are reviewed each month. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 11 In one instance where a service user was admitted with bruising, there had been a delay in recording this, and the need to record and where necessary report any untoward findings on admission was discussed. Risk assessments for falls were in place. In one instance on the first floor the risk assessment had not been updated following a fall, and this was discussed with the Registered Manager. In one service user plan viewed on the ground floor unit, all documentation had been correctly completed following a service users fall. It was concerning that staff spoken with reported that they need to come into the home in their own time in order to have the time to keep documentation up to date, as there is insufficient time allowed during their working day. Documentation for wound care was in place, to include pressure sore risk assessments. Individual care plans had been formulated for each wound, and wound care dressing records had been maintained. Input from the Tissue Viability Nurse Specialist was recorded. There was evidence that where service users had been admitted from hospital with pressure sores, effective action had been taken by the home to treat and heal them. Pressure relieving equipment was seen in use in the home, and service users had been assessed to identify the specific equipment required to meet their needs. For one service user on the first floor a care plan to reflect a need identified on admission was not available, and this was discussed with the Registered Manager. Continence assessments and where relevant care plans for continence needs were available. Nutritional assessments and screening tools were in place, and monthly weights are carried out. Where a specific problem is identified, documentation to address this was in place. Moving & handling assessments were in place. Risk assessments for the use of bedrails were seen, and in one instance this needed to be discussed and written consent obtained from a source other than the service users representative, as they lived a long way away. The registered nurse said that she would discuss this with the GP. For one service user on the ground floor some of the assessments were incomplete and this was addressed on the day of inspection. The importance of completing documentation promptly following a service users admission was discussed. For one service user recently admitted to the home, all necessary documentation had been completed. Records viewed evidenced involvement of other healthcare professionals. This included the Community Psychiatric Nurse, GP, Tissue Viability Nurse, Chiropodist and Optician. The CSCI Pharmacist Inspector carried out an inspection on 23/05/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation MUR stands for medication usage review. The abbreviation MAR stands for medication administration record. Staff were seen caring for and interacting with service users in a gentle and courteous manner. Service users spoken with said that they are well cared for at the home. Visitors commented that staff are helpful and any issues brought to the attention of the staff are promptly addressed. Service users clothing is Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 12 individually labelled, although a problem identified with the labelling machine was being addressed. Some of the service users on the first floor unit were unshaven, but staff explained that this is the choice of the service user and attempts are made throughout the day to encourage them to shave, in the hope they will be happy to comply at some stage. Vicarage Farm Nursing Home DS0000010962.V295968.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): 13, 14, 15 and aspects of 12 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Information regarding service users interests is available and activities are provided to meet the service users needs. Service users rights are respected and advocacy services can be arranged to provide independent representation for service users. Food choices are available and service users dietary needs are catered for, to include meeting any specialist dietary needs or requests. EVIDENCE: Care plans for leisure activities were seen in the service user plans. A programme of activities for the week was displayed throughout the home. The activities co-ordinator tends to carry out activities on the first floor in the mornings, as the service users there have a better concentration level at this time of day. This standard will be looked at in more depth at the next visit. The home has an open visiting policy. Visitors spoken with said that they are made welcome at the home and representatives are kept up to date with any issues that may arise. The home has information regarding advocacy services available to service users and visitors. This included ‘Care Aware’ and ‘Age Concern’ advocacy Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 14 services. There was evidence that service users are on the electoral role and postal votes are arranged where wished. Service users and relatives spoken with said that the food provision is satisfactory. Options are offered and service user choices are recorded. Since the last inspection an Asian cook has been employed on a part-time basis and an Asian meal option is provided at both lunch and supper times. The kitchen was clean and tidy. There was evidence of stock rotation. Cleaning and temperature records were up to date. Risk assessments for food management and for use of equipment are in place. A recent Environmental Health Inspection had taken place and no issues were identified. Vicarage Farm Nursing Home DS0000010962.V295968.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The systems for managing complaints and adult protection matters are robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure, copies of which were on display in the home. The home had received one complaint since the last inspection, and this had been appropriately managed. There is a monthly complaints audit and monitoring form, which provides an overview of the number of complaints made and any outcomes are recorded. Several compliment letters had been received by the home. There is one ongoing POVA concern, which is being managed by the Hounslow Safeguarding Adults Team. There was evidence in the staff training files that staff had received training in Adult Protection. Procedures for ‘Whistle Blowing’ and for reporting of any suspected adult protection concerns were clearly displayed throughout the home. An incident of bruising was discussed, to include the need to report any concerns to the Safeguarding Adults Team. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Sections of the environment are in a poor condition, thus some areas do not provide service users with a homely environment to live in. EVIDENCE: One Inspector undertook a tour of the premises. Generally the home was being maintained, but areas in need of redecoration and refurbishment were noted, and detracted from the homely environment. The enclosed courtyard area was being well maintained with attractive splashes of colour. The Registered Manager said that they do not have a redecoration and refurbishment plan for the year. On the first floor mental health and dementia care unit the colour schemes in the corridors and main day room are mainly very bright and not in line with current dementia research findings. The corridor carpets were stained and marked and in need of replacement. It is clear that the domestic staff work hard to keep the carpets clean, however Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 17 long-term staining and wear and tear means the carpets are now looking very shabby. Alternative flooring had been installed in the dining areas, the small sitting rooms and in some bedrooms. The Registered Manager said that approval has been given for the carpets in the main lounges, which are also very marked, to be replaced. The armchairs in the first floor lounge are old, marked, and several did not have matching seat cushions. In some instances no seat cushions were available at all. The overall impression from this area was very institutionalised, and not homely. The bathrooms viewed were in need of redecoration and some of the flooring was cracked. One bathroom on the first floor is being used as a smoking room. Two service users smoke, and for safety require staff supervision when smoking. The Registered Manager stated that during the summer months the service users can smoke in the courtyard area, but a more satisfactory solution needs to be found for the winter months. There have been plans for some time to convert one bathroom on the first floor into a shower room to meet the service users needs. This has not been actioned. There had been an Occupational Therapy review of the home. There are hoists available on both floors. The home has two passenger lifts. Rails were seen in all the corridors, plus in assisted toilet facilities. The home is purpose built. There are 52 single and 4 double bedrooms. Some of the furniture in the bedrooms was worn and old, and again, this needs to be addressed. The home does have adjustable beds for service users with moving & handling needs. Screening is provided in the double rooms. There is a call bell system throughout the home and these were answered promptly. Concerns about the heating and hot water system in the home had been resolved and the last maintenance visit had been in March 2006. The Registered Manager is monitoring the situation as individual parts of the system have been replaced, however she said that the installation of a complete new heating system had been recommended. Wall-mounted fans are in place to assist with the air circulation on the first floor, and this is effective. The maintenance man undertakes hot water temperature checks. For the month of March 2006 the records indicated that in some rooms the hot water temperature had been above 47° centigrade, and it was not clear what remedial action had been taken to address this. One Inspector spoke with the maintenance man who said that several of the mixer valves had been replaced, which needed to be recorded. The laundry room was generally clean, and action was taken at the time of inspection to ensure that the arrangements for the storage of soiled and clean laundry are abided by. The home was clean and odour-free. Protective clothing to include gloves and aprons are available throughout the home. There is a sluice room with an electric bedpan washer on each floor. Staff had received infection control training and policies and procedures are available. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area in relation to staffing is poor. Quality in this outcome area for the other standards is good. These judgements have been made using available evidence including a visit to the service. The staffing levels in the home were not adequate to meet the needs of the service users, thus placing service users at risk. Staff training in the home provides staff with the skills and knowledge to meet service users needs. Robust systems are in place for the recruitment of staff, thus safeguarding service users. EVIDENCE: On the day of inspection the home was short staffed. The annual budget showed that staffing on the ground floor had been reduced by one carer in the morning and one registered nurse in the afternoon. The Registered Manager said that by careful rostering she had been able to afford some additional care hours for the morning shift. There was no evidence that the reduction in staffing was based on any service user dependency assessments. Previous correspondence had taken place between the then NCSC and Southern Cross Healthcare, who agreed to comply with the previous Regulatory Authority’s Minimum Staffing Notice. During the afternoon of the inspection, the Inspectors observed service user behaviour. Several service users were wandering around the unit, and staff were busy, assisting service users as necessary. At one point there was no member of staff available to supervise in one of the lounges and two service users were quite agitated, trying to sort out who was going to sit on which chair. Several of the service users in this room Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 19 are able to get up and wander around, as was happening at this time. Staff were seen to be very busy throughout the inspection of this unit, and it was clear that several of the service users have high dependency needs, to include high risk factors associated with wandering. The monthly falls audits for the first floor unit identified that the afternoon period is the time when most falls take place, and these had been unwitnessed. An immediate requirement for an action plan to address the shortfalls in the staffing levels was issued. This shortfall also tallies in with the fact that staff do not have the time to update the paperwork during their working hours. There were also shortfalls noted in the staffing for domestic and laundry duties, and the Registered Manager said that she was in the process of recruiting new laundry staff. The home has in place a programme for NVQ in care training. The Registered Manager said that she is aware of the need for 50 of all care staff to be trained to level 2 NVQ in care or the equivalent. The home is also an approved training centre for supervised practice nursing students from overseas, who are completing additional training in order to qualify as registered nurses in the UK. The staff employment files viewed contained all the required information and were up to date. Training records viewed indicated that staff receive induction and foundation training to meet the Skills for Care standards. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The Registered Manager has an open approach to home management, and runs the home effectively in the best interests of the service users. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Shortfalls identified should be easily addressed. The systems for the management of health and safety are in place, thus safeguarding service users. EVIDENCE: The Registered Manager is a first level registered nurse with a post-graduate diploma in nursing. She has a post-graduate qualification in the care of the dying, and is a qualified moving & handling instructor and risk assessment assessor. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 21 Observations made at the time of inspection indicated that the Registered Manager has an open, positive and inclusive approach to managing the home. This was also confirmed by staff, service users and visitors spoken with, and by comments seen on some of the satisfaction questionnaires completed by service users representatives. The last Regulation 26 monthly visit reports received by the CSCI were for January and March 2006. No reports had been received for the months of February and April 2006. Service user and representative satisfaction surveys take place periodically, and shortfalls identified are addressed by the Registered Manager. Relatives and service user meetings also take place and the Registered Manager also has a Managers surgery, where service users and their representatives can raise any concerns. Audits to include housekeeping, facilities, care planning, medication and pressure sores take place. There is a bi-monthly home audit undertaken by the Registered Manager. Maintenance and servicing records were viewed at random. Those viewed were up to date. Fire drill records viewed showed that drills were taking place on a regular basis. The need to clearly identify whether day or night staff had attended each drill was discussed. The fire risk assessment was viewed and this was up to date. Following the last inspection arrangements had been made for sessions in Fire Safety Training. The Registered Manager explained that the majority of staff had attended, and that she was aware of those staff still to attend. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 3 2 2 2 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X X 2 Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP7 OP7 OP8 Regulation 13(4) 17 Requirement Risk assessments for falls must be updated following any falls. All service users needs must be clearly identified on admission. Documentation must be completed promptly after admission. Where a service user is unable to discuss and sign the consent for bedrails, this must be discussed with the representative and healthcare professionals and an appropriate signature obtained. Oxygen stored in the home must be secure and checked regularly. Only lancing devices or pens for professional use must be used for testing blood glucose. That insulin is not allowed to stockpile in the home. A full environmental audit of the home must be carried out. A redecoration and refurbishment programme, with timescales for completion, must then be formulated to address the findings. A copy of this must be forwarded to the CSCI. The décor in the first floor DS0000010962.V295968.R01.S.doc Timescale for action 16/06/06 16/06/06 3. OP8 13(7) 16/06/06 4. 5. 6. 7. OP9 OP9 OP9 OP19OP20 OP21 OP24 13(2) 13(2) 13(2) 23(2)(b) (d) 01/07/06 01/07/06 01/07/06 30/06/06 8. OP19 16(c) 30/06/06 Page 24 Vicarage Farm Nursing Home Version 5.2 9. OP25 13(4) 10. OP27 18(1) 11. OP33 26 12. OP38 18 mental health and dementia care unit must be reviewed in line with recognised good practice in dementia care. The outcome of this must be included in the redecoration and refurbishment programme. Where hot water temperatures are found to be above recognised safe temperatures, there must be evidence recorded of the remedial action taken to address this. The must at all times be suitably qualified, competent and experienced persons working at the care home in such numbers as are appropriate for the health and welfare of the service users. An action plan detailing how the staffing shortages are to be met must be forwarded to the CSCI. Immediate requirement set. Regulation 26 visits must be carried out at least monthly and copies of the reports must be forwarded to the CSCI. There must be evidence that all staff have attended fire safety training at the required intervals. 16/06/06 26/05/06 16/06/06 01/07/06 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. 3. Refer to Standard OP9 OP9 OP9 Good Practice Recommendations That a copy of the warfarin dose/anticoagulant book is kept readily accessible That dosage changes are re-written and signed and dated. That care plans for managing epileptic seizures with or without rectal diazepam are updated. DS0000010962.V295968.R01.S.doc Version 5.2 Page 25 Vicarage Farm Nursing Home 4. 5. OP9 OP9 That the history of allergy is documented on the MAR. That residents at risk of falls have a MUR or medication review. Vicarage Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Farm Nursing Home DS0000010962.V295968.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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