Inspection on 28/04/08 for Vicarage Farm Nursing Home

This inspection was carried out on 28th April 2008.

CSCI found this care home to be providing an Adequate service.

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 Farm Nursing Home 21/08/07

Vicarage Farm Nursing Home 19/10/06

Vicarage Farm Nursing Home 22/05/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Vicarage Farm Nursing Home 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA Lead Inspector Mrs Rekha Bhardwa Unannounced Inspection 28 , 29 April & 4th May 2008 10:15a th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vicarage Farm Nursing Home DS0000010962.V359973.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.V359973.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 Urvasee Shersing Care Home 62 Category(ies) of Dementia (35), Mental disorder, excluding registration, with number learning disability or dementia (5), Old age, not of places falling within any other category (27) Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 27) Dementia - Code DE (maximum number of places: 35) Mental Disorder, excluding learning disability or dementia - Code MD (of the following age range: over the age of 50) (maximum number of places: 5) The maximum number of service users who can be accommodated is: 62 21st August 2007 2. 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 residents and the first floor provides accommodation for thirtyfive residents. 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 residents and their visitors. The fees range from £630 to £900 per week. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 5 Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 16 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 15 residents, 15 staff, 4 visitors and 1 healthcare professional were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and staff have also been used to inform this report. What the service does well: What has improved since the last inspection? Since the last inspection a full time laundry assistant has been employed. No issues with the laundering tasks were highlighted during this inspection. There has been an overall improvement in activity provision in the home, which needs to be further progressed to ensure that all residents undertake activities Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 7 that meet their individual preferences. Staff working in the home had undertaken safeguarding adults training. Staff working on the dementia care unit had received training in dementia care with further training being planned. What they could do better: 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 Farm Nursing Home DS0000010962.V359973.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 Farm Nursing Home DS0000010962.V359973.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the resident assessment undertaken by social services. Vicarage Farm Nursing Home DS0000010962.V359973.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans were not always promptly completed, did not always accurately reflect the condition and needs of the resident and some documentation was incomplete, thus placing residents at risk of not having their needs met. Shortfalls in the management of medications could place residents at risk. Staff care for residents in a gentle and courteous manner, thus respecting their privacy and dignity. Information and knowledge available for end of life care is limited, thus not fully providing for this area of need. EVIDENCE: Service user plans were sampled on each floor. In one viewed the care plans had not all been completed promptly following admission, and a care plan for cognitive impairment had not been fully completed. Some of the care plans were very general in content and were not person centred. In one instance the care plans had been formulated 3 years before, and the condition of the resident had changed markedly in this time. Although this had been addressed to some degree in the evaluation, the need to fully update the care plans to Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 11 provide an accurate picture of the residents’ current needs was discussed. There was evidence of some involvement from relatives in the care plans, but input from residents and their relatives was not found in all service user plans viewed. There is a general review carried out every 6 months with the resident and their next of kin, however these did not include information regarding service user plans being reviewed at this time. Risk assessments for falls were in place, and had been updated following any falls. In 2 of the 3 care plans viewed on the ground floor several shortfalls were noted in wound care documentation. These included gaps in the recording of dressing changes, one pressure sore risk assessment that had not been reviewed for 4 months, and generally a lack of information regarding the progress of each wound. The 3rd care plan was comprehensive and it was easy to follow the progress and care provided for the wounds. Some of the risk assessments had not been reviewed for several months. Assessments for moving & handling, nutrition and continence were in place and had been reviewed. For one resident for whom bedrails were not suitable but an alternative method of ensuring safety when in bed was in use, this had been clearly recorded and signed by the next of kin. Other bedrail assessments had been agreed and signed by the resident or their next of kin. On the first floor the documentation was more comprehensive and up to date, giving a better picture of each resident and their current needs. On both floors, where a resident was scheduled for weekly weighing, this had not always been carried out, and there did not appear to be a system in place for checking that weekly weights are done. It is acknowledged that overall weights were stable and where weight loss had been noted, the resident had been referred to the GP and dietary supplements had been prescribed and were being given. Care plans for continence care needs did not include toileting programmes to promote continence. The standard of 2 out of 3 of the service user plans viewed on the ground floor was poor, and work needs to be done without delay to bring review all the service user plans and bring them up to date. The training matrix evidences that the registered nurses had received recent training in care planning, however this does not appear to have been put into practice. There was evidence of input from healthcare professionals to include GP, Consultant Psychiatrist, Tissue Viability Nurse, Chiropodist, Optician and Dietician. We spoke to one GP and the Consultant Psychiatrist, both of whom said that the staff were efficient, provide clear information and follow through any instructions given. Medication management was viewed on both floors. Medications are stored securely within the home. A list of staff signatures and initials was available. Liquid medications had been dated when opened. There were no gaps in signing for medication administration. The controlled drugs registers had been correctly completed for receipt and administration. The lancing devices in use for blood glucose monitoring are not those approved for care home use. MRHA alerts have been sent to all care homes on several occasions and it is concerning to find that the approved devices are not in use. This must be Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 12 addressed as a matter of priority. On the ground floor we found that two medications had not been dispensed on the ground floor on the second morning of inspection, and this was addressed at the time of inspection. The actual number/amount of liquid and inhaler medications had not always been recorded on receipts, and in some cases medication receipts had not been recorded. For one resident on a medication that has very specific administration instructions these were not recorded on the medication administration record (MAR) or on the medication itself. On speaking to staff they were not aware of the specific administration instructions to be followed. There had been a problem in recent weeks with the fridge temperatures being outside the maximum limit for safe storage, however this had now been addressed. On the first floor for one resident who had been refusing their medication, no explanation had been recorded. The need for the resident to have their medications reviewed was discussed. The medications that had been refused had not been recorded in the disposal book, nor had they been left in the individual blister packs, so it was not possible to ascertain how the medication had been disposed of. One liquid medication was still in use more than a month after it had been opened despite clear instructions on the label stating that it must only be used for one month after opening. Medication audits are carried out and it is concerning that the shortfalls identified at the inspection had not been identified by the home staff carrying out the audits. Staff were caring for residents in a gentle and professional manner and overall the residents and relatives spoken with said that staff provide a good standard of care and do look after the residents well. There was a good rapport noticed between staff and residents, especially on the first floor. An Asian diet is provided for residents for whom this is their preference. Residents were appropriately dressed to reflect individuality and cultural preferences. Religious representatives visit the home from the Christian and Asian Faiths. Information regarding end of life care was very general in some of the care plans viewed, with no specific information regarding residents’ individual wishes. The Operations Manager said that Southern Cross Healthcare are implementing a programme of training for end of life care to ensure that all relevant information is sensitively discussed, so that the wishes of the resident and their families can be recorded and respected. Vicarage Farm Nursing Home DS0000010962.V359973.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 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home has a full time activities co-ordinator, and a diary of activities is displayed on each floor. The activities co-ordinator was engaged in activities with groups of residents, however the need for staff who are supervising in the day rooms to instigate activities also was discussed, so that activities are provided daily throughout the home. The possibility of providing a diary of activities more accessible to residents was discussed. Care plans for ‘working and playing’ viewed were very general and did not identify the individual interests of each resident. The Operations Manager said that work is being done to introduce individual life histories so that the staff can gain the information about each persons past, to include their hobbies and interests. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 14 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was available and on display on the homes notice board. The kitchen was clean and tidy and all the records were up to date. Residents are offered a choice of meals and documentation to evidence this was available. There are two meal choices for lunch and suppertime, plus an Asian diet option. Overall the residents spoken with said that they do enjoy the food and that choices are offered. Where one resident had not enjoyed the meal they had been given, the chef provided an alternative very promptly. Meals to include liquidised items are well presented. We sampled the lunchtime meat and Asian diet options on both days of inspection, and the meals were well presented and tasty. The meat was well cooked and tender. Southern Cross Healthcare is introducing a new meal nutrition management system called ‘NUTMEG’ and the chef was aware of this and the fact that the menus had changed to reflect this. There is a change to the supper options, which now include 2 hot meal options, however the importance of providing residents who are used to and want sandwiches as part of their evening meal with their preferred choice was discussed. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear a complaints procedure in place to address any concerns raised by residents and their visitors. There are robust systems in place for the safeguarding of residents from abuse. EVIDENCE: The home had received 4 complaints in the last 12 months. These had been investigated and information was made available to show that they had been appropriately addressed and responded to. We recommended that the complaints documentation be filed in a manner so that the information pertaining to each complaint is kept together and details of any investigation are also available. The home has adult protection policies and procedures in place that dovetail with the Hounslow Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. Whistle Blowing was discussed and staff understood this. There have been 2 POVA cases in the last 12 months, one of which had been concluded and one is in the process of being investigated. Vicarage Farm Nursing Home DS0000010962.V359973.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24, 25 & 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is clean and there is a homely atmosphere, however repeated shortfalls in redecoration and refurbishment indicate that the environment is not being maintained for the comfort of the residents. Infection control procedures are in place and being adhered to, thus safeguarding residents. EVIDENCE: The home does not have an annual redecoration and refurbishment plan, and it was clear that several areas, to include redecoration of bedrooms, bathrooms, toilets and en suites, corridors, sluice rooms and generally the majority of the home, had not been redecorated for some years. Several carpets to include the first floor corridor carpets were old, worn, stained and in need of replacement. It is acknowledged that the ground floor corridor and communal areas have been re-carpeted. Some armchairs were marked and some did not have matching seat cushions. Many of the bedroom doors do not shut fully and it was explained that they are in need of new hinges to meet fire safety Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 17 standards. The Operations Manager said that this had been identified and was being addressed. The external grounds are in need of attention with weeds growing freely amongst the shrubs. One comment received was ‘the dementia unit at Vicarage Farm Nursing Home is now looking very shabby’, and this statement applies to many areas of the home. A full environmental audit must be carried out and a redecoration and refurbishment plan, with timescales for completion, drawn up to ensure the work is carried out in a timely fashion. One bathroom on the top floor is still being used as a smoking room, although the notice on the front door clearly states that the home is a no smoking area. The rules regarding smoking in enclosed spaces do allow for smoking in care homes, however a room must be clearly designated for this purpose with no potential detriment to other people within the home. This situation needs to be addressed as a matter of priority. There are rails throughout the corridors and grab rails in toilets and en suite facilities. Hoists were available to meet the needs of the residents. We noted that on the ground floor one hoist had been marked as ‘failed’ when serviced a few weeks before the inspection. A notice to identify the hoist as out of order was placed on it at the time of inspection. The importance of ensuring that any items of equipment that are found to be out of order are taken out of commission promptly until repaired was discussed. Some of the furniture in the bedrooms was falling apart, to include some chests of drawers. The environment leaves much to be desired and needs to be addressed without delay (see requirement under Standard 19). It is acknowledged that divan and metal framed beds are in the process of being replaced by profiling beds suited to the needs of each person. The lighting in the first floor corridors was very dim and action must be taken to ensure the lighting throughout the home meets the Lux (150) standard. The home was somewhat warm throughout, however it is acknowledged that the residents seemed comfortably warm. In one room a radiator was out of order and a portable radiator had been placed in the room. The surface temperature was extremely hot and the Operations Manager said that this would be addressed without delay. The home was clean and smelled fresh throughout. The laundry room was clean and tidy and systems were in place for infection control. Residents clothing is labelled and the laundry person was very clear about ensuring clothing is properly labelled and keeps records of work done in this area. A concern had been raised regarding the condition of some clothing, and this was being looked into. Protective clothing to include gloves and aprons was available. Some comment had been received about limited supplies of gloves being available, however this was not evident at the time of inspection. Senior staff did say that they had been working to ensure that gloves are not being worn unnecessarily, and only when providing care that requires their use for Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 18 universal infection control purposes. Many of the staff had received training in infection control. Vicarage Farm Nursing Home DS0000010962.V359973.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is at times short of staff, and therefore the needs of the residents are not being fully met at all times. Systems for vetting and recruitment practices are in place, however repeated shortfalls in this area place residents at risk. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: It was clear from speaking with residents and staff that there are times when the home is short of staff, so the residents’ needs cannot be fully met. An example of this is a resident who could not be given a bath, and other residents having to wait for prolonged periods of time to have their personal care needs met. The duty rosters viewed did not always accurately reflect the number of staff on duty, as they had not always been updated following staffing changes. The home relies heavily on the use of bank staff, and in addition some staff ring in sick so near the start time of their shift it is not always possible to replace them. It was noted that the problem was common at weekends. The need to ensure staffing is appropriate and that staff sickness and absence is being effectively managed in line with company procedures was discussed. Due to the concerns regarding staffing, particularly at weekends, we visited the home on Sunday 04/05/08. At the time the home was appropriately staffed and action had been taken to cover any staff sickness for the Bank Holiday period. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 20 The home has NVQ in care training for staff and the AQAA records that 80 of permanent care staff have attained NVQ level 2 in care. There are plans for NVQ level 3 in care to be introduced. Three sets of staff employment records were viewed. For one member of staff a reference had not been obtained from their most recent employer and no explanation for this had been given. For 2 staff only one reference was available on their file. For one person there was no photograph available on their file. The reason for leaving previous employments had not always been given on the application forms viewed. Application forms, healthcare questionnaires, job descriptions and contracts with hours of work were available on the files. Southern Cross Healthcare has an induction programme that meets the Skills for Care common induction standards, however the abbreviated version in use in the home does not. The training matrix viewed indicated that staff had received periodic training in topics relevant to the needs of the residents. On the dementia floor staff had received training entitled ‘Yesterday, today and tomorrow’, which is training specific to the holistic care needs of each resident living with the experience of dementia. Vicarage Farm Nursing Home DS0000010962.V359973.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, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications to manage the home, however needs to develop her leadership skills in order to manage the home more effectively. Staff do not always find the Registered Manager approachable, and this has led to staffing issues within the home. Systems for quality assurance are in place, however they are not effectively implemented, leading to shortfalls in areas throughout the home. Residents monies are well managed, thus safeguarding residents interests. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 22 The Registered Manager is a first level Registered Nurse and has completed the Registered Managers Award, NVQ level 4 in management, and undertakes periodic training in topics relevant to her role and mandatory training needs. We spoke with several members of staff and there was a common theme that they did not find the Registered Manager approachable. Comment had also been received on questionnaires. They felt that this had led to a ‘blame’ culture and now staff carrying out their duties in a somewhat ‘blinkered’ manner in order to avoid conflicts. This was discussed with the Registered Manager in general terms and she was aware of the importance of effective communication between management and staff. The home has systems in place for quality assurance, however it was clear from the shortfalls identified during the inspection that the systems are not being effectively implemented. Unannounced regulation 26 inspections on behalf of the registered person take place and reports for these are available. Staff meetings, residents and relatives meetings take place every 3 months and minutes of each set of meetings were available. The home did not have in place an annual development plan. The home manages personal monies for several residents. Records viewed were up to date and receipts were available. Monthly reconciliations take place and the records viewed detailed interest being paid to individuals. A sample of servicing and maintenance records were viewed and those viewed were up to date. The home employs a full time maintenance person. Fire drills were taking place for both day and night staff. Risk assessments for equipment and safe working practices were in place. The home has a health & safety committee in place who meet regularly to discuss any health & safety issues. The training matrix evidenced that staff had received health & safety training to include moving & handling, fire awareness, food safety, first aid, COSHH and infection control. Staff spoken with said that they receive training in all health & safety topics. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 2 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 1 X 2 2 X 1 X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X X 3 Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15, 17 Requirement Service user plans must be completed promptly and the information contained therein must be up to date and accurately reflect the needs of each individual and how these are to be met. Unless it is impracticable to do so, input from residents and their representatives must be sought in the formulation and review of the service user plans. Assessments must be fully and accurately completed and kept up to date. Wound care documentation must be complete and up to date. Where a continence care need is identified a clear regime of continence management must be included in the service user plan. The MHRA advice with regard to blood glucose testing must be followed. Medicines must be recorded accurately when received into the home and disposed of. Disposal records must be available. DS0000010962.V359973.R01.S.doc Timescale for action 01/07/08 2. OP7 15(2)(c) 01/07/08 3. 4. 5. OP8 OP8 OP8 15, 17 15, 17 15, 17 01/06/08 01/06/08 01/06/08 6. 7. OP9 OP9 13(2) 13(2) 30/04/08 30/04/08 Vicarage Farm Nursing Home Version 5.2 Page 25 8. OP9 13(2) 9. OP9 13(2) 10. OP9 13(2) 11. OP11 12 12. OP12 12(1)(a) 13. 14. OP12 OP19 17(1)(a) 23(2)(b) & (d) 15. OP21 12(1) 16. OP22 23(2)© Clear instructions for the administration of all medications must be recorded and followed, to ensure medications are safely administered. All medications must be correctly administered, to ensure residents receive the correct dosage. Where a resident is refusing to take their medications this must be reviewed with the GP and where necessary the Psychiatrist to safeguard the resident. Information regarding service users wishes in the event of deterioration in their health, plus their care in their final days must be ascertained and recorded, so that their wishes are respected. The Registered Person must ensure that sufficient and appropriate activities are undertaken in the home. Previous timescale of 16/10/07 not met The care plans for working and playing must reflect the interests of each individual. A full environmental audit must be carried out and a redecoration and refurbishment plan drawn up, with timescales for completion, so that the work is carried out in a timely manner. The smoking room provision in the home must be reviewed to ensure that the needs of residents are met without detriment to other residents, staff and visitors. Relevant signage in the home must be appropriate to the smoking area provision. Where an item of equipment is found to be out of order this must be identified clearly and the item taken out of service DS0000010962.V359973.R01.S.doc 30/04/08 29/04/08 30/04/08 30/04/08 01/06/08 01/07/08 01/06/08 01/06/08 30/04/08 Vicarage Farm Nursing Home Version 5.2 Page 26 17. OP25 23(2)(p) 18. OP27 18 19. OP29 19(1) Schedule 2 12(5) 20. OP32 21. OP33 24 until repaired, in order to safeguard residents. The lighting throughout the home must be reviewed to meet recognised (Lux 150) brightness levels to provide appropriate lighting for those living, working and visiting the home. The home must be appropriately staffed at all times to ensure the needs of the residents can be met. The Registered Person must ensure that all staff records are complete. Previous timescale of 30/10/07 not met The Registered Manager must ensure that there are systems in place to ensure that good professional relationships are maintained between management and staff in order that communication is clear and effective. Effective systems for quality assurance must be in place and prompt action taken to address any shortfalls identified in order to protect the residents. 01/09/08 16/05/08 01/06/08 01/06/08 01/06/08 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 Where it has been identified that a resident is to be weighed weekly, there should be a system in place for checking that this has been carried out. Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vicarage Farm Nursing Home DS0000010962.V359973.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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