Care Home: The Old Vicarage

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What the care home does well The home continues to offer a wide range of opportunities for the residents. Staff have an awareness of the individual needs of each resident. The staff team are committed and focused on the aims of the home, such as offering daily choices and new experiences for the residents. What has improved since the last inspection? The home had been carrying out medication audits and checks, see further on for more information about medication. Medication, when administered or discarded had been recorded, so that there was now a clearer audit trail. The communal carpets had been cleaned. What the care home could do better: Risk assessments need to be completed on all residents` potential and identified risks. The quantities of medication need to be clearly recorded onto the Medication Administration Records. Medication that is kept in bottles or boxes must be counted. Overall the medication systems need to be more robust in order to safeguard the residents. CARE HOME ADULTS 18-65 The Old Vicarage 75 The Greenway Uxbridge Middlesex UB8 2PL Lead Inspector Sarah Middleton Key Unannounced Inspection 2nd July 2008 09:05 The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 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 The Old Vicarage DS0000061744.V366674.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 Adults 18-65. 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. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address 75 The Greenway Uxbridge Middlesex UB8 2PL 01895 454710 01895 454711 michele.kelly@the-old-vicarage.org 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) Autism Consultants Limited Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Old Vicarage DS0000061744.V366674.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 only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 Date of last inspection Brief Description of the Service: The Old Vicarage is located in a large house that has been adapted to offer the space and homely environment for the residents to live in. It is near to a main road that leads into the local town Uxbridge where there are good transport links into London. The service has its own transport and is located near to the college that some of the residents access. The Old Vicarage is a service that can offer accommodation for adults with Autism and or associated disorders. Formerly this service was registered at The St Mary’s Centre. The residents and staff moved to the Old Vicarage in November 2005. The Registered Provider is Autism Consultants Limited. The Registered Provider provides schools and a college for people with Autism and associated disorders. They also own an agency, which provides staff to various services. The residents living at the Old Vicarage are able to access this college. At night the home has a sleeping-in member of staff who is available for residents. There is also an on-call person, usually the Registered Manager or the Deputy Manager who is available to offer additional support and advice. Fees vary depending on whether residents receive one to one support, (this is reviewed on a regular basis) and whether they attend the college owned by the Registered Provider. The residential fees range from £1,522.33 to £2,246.67 per resident per week. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out between the hours of 9.05am5.15pm. Three residents and one member of staff were spoken with. Three residents, three relatives and three health professionals returned postal surveys to the Commission. Comments are included in this inspection report. The Acting Manager is in the process of applying to be the Registered Manager. A new Deputy Manager had recently joined the staff team and there was one full-time staff vacancy at the time of the inspection. There were two resident vacancies. The four previous requirements had been met and six new requirements were made from this inspection visit. All of the key National Minimum Standards had been assessed. What the service does well: What has improved since the last inspection? The home had been carrying out medication audits and checks, see further on for more information about medication. Medication, when administered or discarded had been recorded, so that there was now a clearer audit trail. The communal carpets had been cleaned. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 6 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. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a process in place to assess prospective residents before they move into the home. EVIDENCE: Two newly admitted residents were spoken with and they confirmed they had met with staff and other residents prior to moving into the home. One postal survey from a resident said that, “When I moved into the home I was pleasantly surprised”. The Acting Manager described the pre-admission process, which is carried out over a period of time. The Acting Manager stated that usually it is the Contracts Manager who initially visits the prospective resident. We were informed that at this initial stage the Acting Manager is often not involved in deciding whether the pre-admission assessment is to go ahead. It is crucial that the Acting Manager, who is aware of the other resident’s needs, is fully involved in the initial stages of meeting a potential new resident. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 9 Thereafter there are opportunities for the prospective resident to spend time in the home and this is when the Psychologist and staff begin assessing their needs. Where possible the home requests as much information from the family and referring professionals, such as reports and assessments. An assessment was seen that had been completed by the Psychologist, this along with a risk assessment that is completed by family members, forms part of the decision as to whether the home can potentially meet the needs of the new resident. All new residents stay in the home on a six- week trial period where the placement is then reviewed. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans reflect the resident’s needs and how these will be met. Residents are supported to make daily everyday decisions. Risks need to be considered, assessed and recorded in order to support residents appropriately. EVIDENCE: Samples of care plans were viewed. These related to the recently admitted residents. The care plans consider various aspects of residents’ lives, such as, their social, health and personal care needs. Resident’s cultural and religious needs are also assessed. Care plans are reviewed on a monthly basis or sooner, if needs change. Every six months there is a main review where the resident, their family and relevant professionals are invited to attend. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 11 We were informed that residents are encouraged to contribute their views. There was no evidence of how residents contribute to their care plan and this was discussed with the Acting Manager. Evidence and the opportunity to formally record the resident’s views should form part of the development of the care plan. Keyworkers meet with residents on a regular basis. It was discussed with the Acting Manager and Deputy Manager that it would be good practice for a record of these meetings to be developed. We viewed a small sample of daily records. These outlined the significant events that had occurred. We discussed with the Acting Manager and Deputy Manager how the home was meeting the needs of another resident. The staff team had been considering ways to engage with this resident, as their needs had been changing, but this had proved, for the most part, unsuccessful. We were satisfied at this inspection visit, that the home were doing everything they could to review the placement and consider how to best support this resident. The Acting Manager should continue to look for support and guidance regarding how this situation can be resolved. Where possible residents are supported to manage their own finances. The residents currently living in the home did not have independent advocates. The residents have the support of family members and are often capable of voicing their own direct views to the staff team. Those residents asked said they felt able to make decisions about their lives. One postal survey from a resident, replied that staff always listen to them. We viewed a sample of risk assessments. These had been considered and recorded by the Psychologist and the family. These risk assessments formed part of the pre-admission stages and the staff team had not completed a detailed risk assessment since the two residents had moved into the home. Although it is recognised that there was some information about potential risks, as the staff team become familiar with the needs and risks of the resident, documentation must then be completed and reviewed on an ongoing basis. The members of staff working in the home need to know the possible risks when supporting a resident. A requirement was made for this to be addressed. Subsequent to the inspection visit, we were informed that risk assessments had been completed. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to take part in activities both in and outside of the home. Residents are encouraged to maintain personal and social relationships. The rights of the residents are respected. The meal provision provides residents with a varied and overall balanced diet. EVIDENCE: Four of the residents go to a local College, which is for people with Aspergers and Autism, five days a week. Another resident is now a mentor and visits the College to support the students. We spoke with a resident who said they were learning new skills at the College and enjoyed going there. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 13 Another resident spoken with has one day a week voluntary work at a local farm and is supported to attend this with a member of staff. There are often occasions where residents can have one to one support from a member of staff. We discussed with the Acting Manager and Deputy Manager the issues regarding one resident who refuses to take part in most activities. The staff team continue to try to motivate and involve the resident in daily tasks, but this is proving difficult. The staff team will keep motivating this resident with the hope that they will engage in activities on a more regular basis. Some of the residents had agreed to go on holiday together and this has been arranged. Residents had made specific requests that they would want for the holiday and this has been listened to and suitable accommodation was found that would meet individual needs. The residents spoken with said they often walked to places or sometimes used public transport. None of the residents currently have freedom passes, which means they could travel for free on public transport. Both residents and staff have looked into trying to appeal this decision, but so far they have been unsuccessful. The residents would benefit from free travel, so that they can access more resources without there being a cost each time. The home has a small computer room and a room in the garden where residents can go to and listen to music or have some quiet time away from others. One resident asked, said they liked to use this room when they wanted to get away from the house. One comment from a postal survey did say that sometimes they had to go out with all the other residents, which they sometimes did not want to do. The Acting Manager was aware of one resident who had requested to not always take part in communal activities and this had been listened to and addressed. All the residents have contact with family, friends and partners. Visitors can see the residents in the home or often residents visit their family and friends away from the home. One resident confirmed they use the public payphone to call family members. All the residents have keys to the front door and their bedrooms. The residents can go out without a member of staff, although some residents prefer to be with staff. Residents confirmed they receive their own personal mail and individual shelves were seen at the main entrance, where the post is distributed. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 14 Residents are encouraged, once a week, to shop, prepare and cook a main evening meal for everyone with the help of a member of staff. Those residents asked said they quite liked making a meal each week as they could learn how to make different meals. One resident purchases their own food and prepares their own meals. Those foods opened were covered and dated in the fridge. Fridge and freezer temperatures had been taken and were within an appropriate range. Knives are kept in the kitchen. This was raised with the Acting Manager, who stated that should there be a potential risk, then knives would be locked away. There are no current identified risks. Menus are planned each week and aim to incorporate healthy fresh produce. It is recommended that staff, where possible, record the meals individual residents eat so that the staff team can monitor the meals eaten. Subsequent to this inspection visit, we were informed that meals are now being recorded. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents, if needed could receive personal care in their preferred way. The health needs of the residents were recorded and were being met. The medication shortfalls and errors noted could pose a risk to the welfare of the residents. EVIDENCE: The residents do not need direct support with personal care. Some residents need encouragement to bathe or change their clothes. Within reason residents can choose when they go to bed or get up in the morning, depending on whether they have commitments, for example going to College. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 16 Health needs had been recorded on the care plans viewed. The home has a new Psychologist who will be involved in the pre-admission process and can offer one to one support to the residents. The home uses a medical appointments form to record when a health professional has seen a resident. The nature of the visit, along with the outcome is recorded and this assists with monitoring any issues a resident might have. All residents have a GP and can access the dentist, optician or chiropodist. A sample of medication was viewed. The staff team had recently attended medication training, although the Acting Manager is looking to find more suitable training, as this had not met the needs and expectations of the staff team. New staff shadow experienced members of staff when they are administering medication. The local Pharmacist carries out a monthly audit. Evidence was seen that the home records when medication had been discarded and is being returned to the Pharmacist. When residents are going away a form is used to evidence what medication has been given to the resident to take with them. If a resident is capable of self-medicating, then this is carried out very slowly. The staff team would carry out a risk assessment and from there the resident would receive medication to keep each day, and this would then increase on a gradual basis. Each resident has a lockable cupboard in his or her bedroom where the medication would be kept in. Counts were carried out with the Acting Manager on medication that was in boxes and not in a blister pack. Errors were noted in the following areas. • The quantities delivered into the home had not been recorded for Diclofenac on the Medication Administration records, (MARS). Therefore it was not possible to carry out a check to see if it had been correctly administered. A requirement was made for quantities to always be recorded so that checks are then possible. The Acting Manager stated that in the future any extra medication left from the previous month will not be carried over, but will be returned to the Pharmacist. This practice then minimises confusion and errors occurring. • One medication had “approx 40” written on the MARS form. This had been due to the home not having a suitable counting tool to use to count medication in a bottle or container. It is recommended for the home to purchase such a tool so that actual counts can be carried out on all medication. • We counted Buspirone 5mg, but found there was a discrepancy and that there were 4 extra tablets in the home. The staff team must be clear if a resident is going on social leave but not taking medication with them (as the relatives might have a supply in their own homes). The MARS forms need to reflect what has been administered or given to a resident to take on social leave. This then enables full checks on medication to be carried out without the need to consider if there has been an error. A requirement was made for the MARS to be correctly used and completed. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 17 • Finally, although monthly checks and audits had been carried out and homely remedies had been counted. The checks had not included counting the loose, unblistered general medication. Had this been occurring, the above errors might have been noted and action to investigate these errors could have been taken. A requirement was made for all the medication, which is not in a blister pack, to be counted and recorded onto the audit forms that the home uses. Furthermore, any resident, who is self-medicating, must also be aware that the staff team would need to carry out an audit of their medication being kept in their bedrooms. The shortfalls were discussed with the Acting Manager, who agreed to carry out a full medication audit, with the Deputy Manager this week. The home has a staff team meeting the week after the inspection and these issues will be discussed. Subsequent to the inspection visit, we were informed that a counting tool had been purchased, discussions to seek further, more appropriate medication training had taken place, the Acting Manager and Deputy Manager were carrying out full medication audit checks on all medication and that a staff list of signatures had been completed. Furthermore staff had been given the medication policy and a quick reference guide to dealing with medication had been developed for the staff team. We were satisfied that the Acting Manager will continue to monitor this Standard to ensure residents are safeguarded. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are listened to and their concerns would be acted on. Systems are in place to safeguard the residents. EVIDENCE: Those residents asked said they would talk to staff if they had any concerns. The returned postal surveys also confirmed that residents knew how to make a complaint. The home has placed an anonymous complaints box in the main entrance hall, to encourage the residents to feel confident in voicing their concerns. Regular resident meetings are held, where residents can also use this opportunity to raise complaints or issues. There is one ongoing complaint that is being looked into. This has been ongoing for approximately eighteen months and the Acting Manager is keen for this matter to be resolved. We were satisfied that this complaint was being dealt with. There have been no safeguarding issues or referrals. Some members of staff might benefit from attending refresher training on the subject of safeguarding vulnerable adults. Subsequent to this inspection visit we were informed that training on this subject had been booked for September 2008. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 19 We counted, with the Acting Manager, two resident’s personal monies. All money is locked in the office of the home. The home can hold onto residents’ money, if the resident is not able to appropriately manage their own finances. The residents sign for money they are taking out and can go to the bank to withdraw money. If a member of staff has carried out a financial transaction, then receipts are obtained. The Acting Manager agreed to introduce a daily count of the resident’s money and these checks will be recorded. The checks and counts carried out at the time of the inspection were correct. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a welcoming and clean home. EVIDENCE: We carried out a tour of the home and viewed a sample of rooms. The main communal carpet had been cleaned, as it had several marks at the last inspection. However, as it is a light carpet it is not practical and shows marks and stains. The Acting Manager would like to have a different carpet that is more suitable for the home. A postal survey, completed by a resident, also remarked on the marks on the carpets. It is recommended that these carpets be changed so that the home looks more inviting and homely. Various improvements had been carried out, such as, new dishwasher, residents’ bedrooms have new furniture, garden furniture and the large room in the garden now has a new sofa and stereo. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 21 The home has a maintenance person who visits on a regular basis to maintain jobs needing to be done. The staff and residents keep the home clean and residents are expected to keep their own bedrooms clean and are given tasks to complete around the home. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and experienced staff team supports the residents. The recruitment procedures need to be followed in order to safeguard the residents. The staff team need all the skills and information in order to support the residents safely and appropriately. EVIDENCE: The staff team comprises of a small team of permanent staff and regular bank staff. On the occasion where agency staff are used, they are also familiar with the home, as the agency is affiliated with the same Registered Provider. The staff team have experience working with people with Aspergers and Autism and are competent to deliver quality care. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 23 The Deputy Manager is in the process of enrolling to study for an NVQ level 4. Some staff have obtained NVQ level 2 or 3 and there is an expectation that the bank regular staff will study for an NVQ. We viewed the rota, the hours staff work are flexible and meet the needs of the residents. There was one staff vacancy at the time of the inspection. There are some shifts where there is only one member of staff working at the week-end, this is usually when many of the residents are away visiting family members. Other times there are staff working a mid-shift, so that they are available to support residents in the morning and afternoon. The Deputy Manager works some shifts and occasionally sleeps over in the home, so that she is able to work alongside the staff team. There is always either the Acting Manager or the Deputy Manager on call to respond to any emergencies. The staff team meet on a regular basis. A postal survey from a relative remarked on how the “contact is good” between the staff team and the relatives. Another postal survey from a relative, commented on how the home treats their relative as a “person”. We viewed a sample of staff employment files regarding the most recently appointed staff. The Deputy Manager’s file initially did not contain a completed application form or health declaration, this was later faxed during the inspection by the Human Resources department. Two references were also seen and a Criminal Record Bureau Check had been carried out. The second file viewed had several documents missing. We were informed that there was no Criminal Record Bureau Check and therefore this member of staff was not working unsupervised with the residents. The two written references were not available, there was not a recent photograph of the member of staff and a signed health declaration form was not available. Subsequent to this inspection visit, we were informed that this member of staff had a POVA 1St check, had a recent photograph and had completed a health declaration. The two verbal references would still need to be in writing and this was going to be asked for. A third employment file was seen and this contained all the required documentation, apart from a second reference. This member of staff had worked in the home for over eighteen months, and had worked in one previous place of work that had provided a written reference. This issue was discussed with the Acting Manager, as there needs to be a second reference, if this is not to be from an employer, then it should be personal or from a professional. After the inspection visit, we were informed that there had been a second reference on file, but that it had not been dated. A requirement was made regarding this Standard, as staff employment files need to contain all the required information at the time of the inspection. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 24 Induction and training for staff was looked at. The home uses a detailed induction that new staff work through over a period of six weeks. This covers a range of relevant topics and scenarios. We viewed staff individual training records and identified there were some staff in need of refresher training in fire awareness and food hygiene. A requirement was made for these two training courses to be booked. The Acting Manager and Deputy Manager also spoke of looking into staff receiving training on basic counselling skills. Some staff had received training on the new Mental Capacity Act 2005. Training and information is also provided on Aspergers and Autism related subjects. We discussed the benefit in having an overall training matrix that clearly shows the training booked and attended for each member of staff. The Deputy Manager is looking to book training courses and was in the process of completing a detailed training matrix. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The views of the residents are obtained and considered by the staff team. The health and safety of the residents are promoted and protected. EVIDENCE: The Acting Manager is in the process of applying to become the Registered Manager. She is studying for an NVQ level 4 and Registered Managers Award. The Acting Manager has been proactive in making improvements and changes in the home over the past few months she has been in post. Now the Deputy Manager is in post there can be a focus on reviewing the running of the home and updating areas as and where necessary. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 26 Residents had completed questionnaires in 2007. The Acting Manager and Deputy Manager were looking to make alterations to these forms to ensure they are suitable and person-centred. There was an overall quality review report from 2007 and this was discussed with the Acting Manager who will need to update this report to reflect the past few months. Regulation 26 visits take place each month and these reports are forwarded on to the Commission. The home has a development plan and this was viewed. This provides some aims and objectives of where the home is planning to move towards over the forthcoming months. The home is looking into having events where parents can meet each other at the home. Samples of maintenance checks were viewed. The Gas Safety and Portable Appliance Test were up to date. Fire drills had been held on a regular basis with different members of staff. The fire risk assessment was viewed. The Acting Manager and Deputy Manager said they had attended training on how to complete a fire risk assessment. This was not confirmed at the inspection. The fire risk assessment recorded significant hazards within the home. This document is updated every year. The Deputy Manager stated the home had the current information on risk assessing fire in a care home. The Acting Manager should also consider if there are any residents who might fail to respond to a fire, as this should also be risk assessed. Water temperatures are taken and shower heads and taps are regularly descaled to prevent the build up of limescale. This procedure can minimise Legionella being present in the water systems. The Acting Manager will arrange a professional company to visit the home on an annual basis to test for the presence of Legionella. We viewed the accident book and there had been no accidents in the past year. The staff team inform the Commission of any significant events that have occurred, using the Regulation 37 forms. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 3 x The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13(4)(c) Requirement Timescale for action 31/07/08 2. YA20 13(2) 3. YA20 13(2) To ensure risks have been assessed, detailed risk assessments must be completed and available for inspection. 03/07/08 To protect residents, the Medication Administration Records must be accurately completed and used to record any handling of medication, such as when a resident is going on social leave. This record must clearly record if the resident has or has not taken the medication with them on social leave. In order to safeguard the 03/07/08 residents’ loose medication, kept in bottles and boxes must be counted and recorded. To protect the health and safety of residents, the quantity of each and every medication in the home must be clearly recorded onto the Medication Administration Records. 03/07/08 4. YA20 13(2) The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 29 5. YA34 Schedule 2 6. YA35 In order to safeguard residents, staff employment files must contain, evidence of two written references, signed health declaration form and a photograph of the member of staff. 18(1)(a)(c)(i) To support residents appropriately and safely, staff need to receive training in, safeguarding adults, fire awareness and food hygiene. 21/07/08 31/10/08 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. 2. 3. 4. Refer to Standard YA17 YA20 YA20 YA24 Good Practice Recommendations It is recommended that where possible, individual meals are recorded. It is recommended there is a list of current staff trained to administer medication, along with their signatures. A counting tool should be purchased so that loose medication can be safely counted and recorded. The carpet in the main communal areas is light and easily marks and stains. It is recommended for this to be changed to a more practical colour. The Old Vicarage DS0000061744.V366674.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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