Care Home: The Old Vicarage Nursing Home

What the care home does well The service continues to offer a good quality of care to people with dementia and mental health needs.There continues to be a positive approach to health care issues. Health care needs are clearly defined in care plans and actions taken to ensure health needs are met. There are regular reviews of health and medication with the doctor. Clinical practice is good. Visitors told us that they are `warmly welcomed into the home at all times`. The care staff showed signs of compassion to the people who use the service and respected their privacy. The home was very clean and tidy in all areas and there was evidence from relatives and at the inspection that the laundry offer an excellent service. What has improved since the last inspection? Food provision and menus have been reorganised and the people who use the service and relatives have noted improvements. The dining room has been painted and appears brighter and more inviting. Staff training has been organised and mapped on a training matrix. The manager has a training schedule, which she is following and she has purchased booklets to support some of her training subjects. New staff are employed on receipt of a clear Protection of Vulnerable Adults check and they work under supervision until their Criminal Record Checks are obtained. The manager has slowly moved the home forward to meet the previous requirements and she has further plans to ensure that the standards are maintained and ever improving. Although it has taken 12 months to action the requirement, the curtains are to be fitted in the lounge area on 20th August 2008. We contacted the fabric company during our visit and they faxed over to us the quote and the fitting date as proof. Supernumerary time for the manager has increased to two days. The medication processes have been improved and this includes staff signing medication records and medication administration. What the care home could do better: CARE HOMES FOR OLDER PEOPLE The Old Vicarage Nursing Home 160 High Street Chasetown Nr Walsall WS7 4XG Lead Inspector Key Unannounced Inspection 30th July 2008 08:15 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 The Old Vicarage Nursing Home DS0000022358.V368992.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. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Nursing Home Address 160 High Street Chasetown Nr Walsall WS7 4XG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01543 685588 01543 683306 Morecare Limited Jennifer Margaret Khadoo Care Home 27 Category(ies) of Dementia - over 65 years of age (27) registration, with number of places The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. DE Dementia over the age of 60 years for 27 persons Date of last inspection 20th August 2007 Brief Description of the Service: The Old Vicarage Care home provides specialist-nursing care to people over the age of 60 years who have dementia. This nursing home is in the same ownership as the adjoining nursing home on the same site, but is run independently of each other. The service is located on a main road in Chasetown. It is near by a few shops. Accommodation is on two floors with shaft lift access. There is a large lounge area with recessed areas and separate dining area. Four bedrooms are for shared use. There are no en-suite facilities but good access to toilet and bathroom areas. The building is well maintained internally and externally. There is a medium sized garden with a sun patio and seating area. This is accessed via a ramp and suitable for wheelchairs. There are sufficient car parking facilities. Fees Highest £350 Lowest £595 The fee information given applied at the time of the inspection; persons may wish to obtain more up to date information from the service. The Old Vicarage Nursing Home DS0000022358.V368992.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 that that people who use this service experience good quality outcomes. This unannounced inspection took place on 30th July by the lead inspector. The manager was at the home and participated in our inspection process. The inspection included the following elements; Observations of the building including communal spaces and bedrooms. Observation of records relating to provision of care, Discussions with people, who use the service, Case tracking whereby we select several people who use the service, chat to them and look at their care plans and lifestyle in the home. Discussions with several of the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, training, recruitment and health and safety. The home manager sent us their Annual Quality Assurance Assessment (AQAA) when we asked for it. This document was completed to a good standard and gave us all the information we asked for. We have dealt with one anonymous complaint since our last inspection; which we have now been closed. People who use the service were very complimentary about the home. One lady said, “We are all happy here including the staff. My daughter wouldn’t leave me here if she were worried. We have plenty to do, the food is getting better and the staff keep me going.” One visitor said, “I can sleep at night now, knowing mum is well cared for and safe.” Another visitor said, “ I went to a few homes before mum came here and I chose well, the staff are very switched on to the residents needs and give a good quality of care and attention. The laundry facility is wonderful. The food has been a problem but the manager seems to have improved things.” What the service does well: The service continues to offer a good quality of care to people with dementia and mental health needs. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 6 There continues to be a positive approach to health care issues. Health care needs are clearly defined in care plans and actions taken to ensure health needs are met. There are regular reviews of health and medication with the doctor. Clinical practice is good. Visitors told us that they are ‘warmly welcomed into the home at all times’. The care staff showed signs of compassion to the people who use the service and respected their privacy. The home was very clean and tidy in all areas and there was evidence from relatives and at the inspection that the laundry offer an excellent service. What has improved since the last inspection? What they could do better: • • Induction training timescales had lapsed and this should be completed within six weeks of commencement of employment. A fire evacuation plan must be put in place and the risk assessment further personalised. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 7 • • • The teatime menu choice should be listed with the actual food choice on offer in the form of a menu, although hot snacks are being offered this is not displayed. Meals cooked in the home should be considered (rather than in the sister home on site) and this would further support the progress made with regards to meals and meeting people who use the services needs. Requirements made at the last visit have been met but out of the timescale and this has led to some frustration in the home for the manager and staff. The operations manager must support the manager to meet the timescales. They are given to ensure appropriate action is taken and should not be dealt with lightly. 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 Nursing Home DS0000022358.V368992.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 The Old Vicarage Nursing Home DS0000022358.V368992.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): Standards 1,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking of using the service are given the information they need to make an informed choice about moving in. People only move into the service following a full assessment of their needs being carried out. EVIDENCE: The service has developed a statement of purpose, which sets out the aims and objectives of the home. This document needs further reorganisation and personalisation. The manager is taking it upon herself to ensure the document is of a good standard and suitable for the people who use the service. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 10 Photographs are to be included to assist the people who use the service in making a decision. The Statement of Purpose is made available to individuals in a standard format. The manager records the initial pre-admission details on an enquiry form prior to completing the assessment. A pre-assessment is then completed to assess that the home can meet the individuals needs. This process ensures that the individual is suitable for the home prior to the manager offering a place. We saw care records that showed us that appropriate pre-assessments were carried out before the individual moves into the home. The manager was able to demonstrate how the service has undertaken the assessment and a relative we spoke to in the home further confirmed this. Staff have the necessary specialist skills and ability to care for individuals who are admitted and this is evidenced through training, care experience and relatives spoken to. One lady spoken to told us that she “was welcomed into the home and settled in very quickly because the staff was so kind to her”. A visitor told us; “ I went to a few homes before mum came here and I chose well, the staff are very switched on to the residents needs and give a good quality of care and attention”. Individuals are provided with a statement of terms and conditions or a contract before admission to the home and also a letter of confirmation from the manager to give them assurance that their needs will be met. The contract gives basic information on what people can expect to receive for the fee they pay. The contract sets out terms and conditions of occupancy. The contract is normally reviewed if people’s circumstances change. The service does not admit people who require intermediate care. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health, personal and social needs are recorded in a plan of care and are being met. Medication policies and procedures increase medication safety. People are treated with respect and their right to privacy is upheld. EVIDENCE: From our case tracking it was evident that people who use the service receive personal and healthcare support using a person centred approach with support based upon the rights of dignity, equality, and respect. Some people who use the service were able to tell us that they are respected and very well looked after. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each care plan. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 12 A new care plan system has been introduced. Staff are amending this to meet the needs of the individuals and to ensure correct and clear recording of events. Personal support is varied depending on the individuals’ needs and preferences. The delivery of personal care is also individual and is flexible to each person’s ability. Relatives spoken to told us, “The staff encourage the residents to do things for themselves.” and “ The staff do respect privacy and dignity and are sensitive to the individual people.” Staff do respond to individual choices. One carer spoken to told us, “We are knowledgeable about the people who live here and know their preferences. People are supported and helped to be independent and can take responsibility for their personal care needs if they want to.” Staff were seen to listen to people and take account of what they wanted. People who use the service have full access to healthcare and specialist nursing services. Tissue viability nurses and continence nurse specialists have visited the home recently to support the staff. The Community Psychiatric nurse visited during our inspection. The local doctors’ manage the overall care of the individuals in the home. Each Monday the doctor visits the home, but he will visit the service at other times as required. At the time of pre admission assessment being carried out the manager ensures that the home has the aids and equipment that they need for the person. This equipment is well maintained to support them and staff in daily living. We saw records of hoist servicing which means that the service is taking the correct action to make sure that equipment is safe and in good working order. The managers’ aims and objectives reinforce the importance of treating individuals with respect and dignity. She observes staff working with people who use the service and maintains an open door policy for everyone at the home to speak to her should they need to. The home has amended their medication administration system to ensure that procedures and practice follow the policy and procedure. We saw that medication records were fully completed, contain required entries, and were signed by the administering member of staff. We observed one nurse carrying out the medication round proficiently. There was evidence that the manager assesses new members of staff for competence with administration of medicine and further training is given. The Old Vicarage Nursing Home DS0000022358.V368992.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): Standards 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. Peoples’ lifestyles mostly match their expectations. People maintain contact with their families. Choice is offered to people who use the service to meet their daily life preferences. Menus and food offered generally meets people’s needs and choices. EVIDENCE: The routine of daily life is made flexile for the people who use the service. One relative spoken to told us “ Mum is sometimes in her bedroom and sometimes in the lounge. She likes the way the staff allow the people to walk about the home”. We saw that an activity plan was on display in the dining room. People to join in activities and craft use this area. One carer spends dedicated time with the individuals and records of activities carried out are kept. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 14 One to one sessions and group activities are offered and provided. The people who use the service told us that they ‘enjoy dominoes, bingo, art, hand massage, reminiscence and sing-a-longs’. Occasionally fish and chip suppers are arranged and film nights are planned. Relatives are invited to join these events if they wish. The manager is planning to start a newsletter for the people who use the service and their families, to advertise events, birthdays and general news about the home. One lady who we spoke to told us that she ‘really enjoyed dancing and singing and occasionally the staff danced with her in the lounge’, which she really loves. This person also told us that ‘things were better now at the home, much more going on. The staff are all lovely and friendly’. She said the ‘meals have improved, the potatoes are sometimes hard but that can happen. She liked the dining room now it was brighter’. She commented that if she did not like a meal the staff would swap it for something else. Relatives meetings are organised. These are advertised and some relatives do attend. Minutes of the meetings were kept at the home. We saw many complimentary ‘thank you’ letters from grateful relatives who wished to show gratitude to the staff for their ‘excellent’ delivery of care and attention. The menus are displayed. They are operated on a three weekly cycle. We saw that the breakfast menu offers a good choice and the lunchtime main meal offers an alternative meal. People who use the service told us that ‘sometimes the meal that arrives is not on the menu for that day’. The manager is addressing this by asking the kitchen to inform them of any changes. The teatime menu does not specify any actual meal but a bland statement, which includes sandwiches and cake. The manager has begun to address this by offering cheese, egg or tomatoes on toast, which the individuals are really enjoying. The menu is to be further amended. The manager is planning to introduce a picture menu to assist the people who use the service to make the right choice of meal. Photographs of plated meals will be gathered together to show the individuals if they are unsure about which meal to choose. The Old Vicarage Nursing Home DS0000022358.V368992.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): Standard 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are confident that their complaints will be acted upon and they are protected from abuse. EVIDENCE: Relatives and people who use the service told us that they were confident that if they made a complaint it would be taken seriously and dealt with appropriately. One lady told us, “If we had a problem we would just speak to the manager and she will put things right, but we don’t need to because the staff are very kind and wouldn’t upset any of us.” One relative said that the managers’ door was always open and any concerns would be dealt with straight away so issues never become complaints. Staff have received an update in Protection of Vulnerable Adults and were confident in whistle blowing should the need arise. No safeguarding issues had been reported since the last inspection. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 16 We received one anonymous complaint about this service. It contained information that could not be substantiated and was now closed. The manager has not received any written complaints. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19, 20, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a safe, well-maintained home, which has accessible indoor and outdoor communal facilities. People who use the service are encouraged to remain independent. The home is well maintained and exceptionally clean. EVIDENCE: The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 18 The service’s Annual Quality Assurance Assessment (AQAA) tells us that a continued refurbishment program is on-going, a number of bedrooms have been redecorated along with the communal areas. The home continues to be odour free and the cleaning schedule is checked at regular intervals. The home has recently appointed a Head Housekeeper to monitor the cleanliness of the home. New chairs have been purchased for the lounges. The dining room tables have been refurbished and the room has been redecorated. Curtains for the lounges and conservatory have been on order and are to be delivered and fitted in the 3rd week of August 2008. This information we evidenced to be correct during our inspection for instance, We saw that the dining room had been painted and the dining tables refurbished. This area is much more inviting and the people who use the service commented that they thought it was much better. Several bedrooms had also been redecorated; we saw that these were bright and homely. The bedroom furniture is of good quality and many of the bedrooms are personalised by the individuals and their families. The lounge curtains are to be fitted at all the windows to bring the two lounge areas to an acceptable standard. Proof from the curtain fitters was faxed to the inspector during the visit. We found the home to be odour free and exceptionally clean. The domestic lady we spoke to said ‘the team of cleaners work hard to maintain a home, which is clean and welcoming. The cleaning schedule is followed to ensure that the standard is kept. Staff are vigilant to any problems, which may arise, and they alert the domestics to this’. We looked at the laundry and sluicing areas and found that these provide adequate safeguards against infection. The home has been well maintained since our last inspection and health and safety issues for the people who use the service are monitored, to ensure their personal safety. Independence of people who use the service is encouraged to maintain normal life styles and the staff do offer support to those who require it. Equipment is available for those individuals who need support, plate guards were seen being used to assist meal times and feeding. Hoist and bath aids are maintained and serviced in the home. There is a secure patio area to the rear of the property with seating and this allows people who use the service wander safely as they wish. The weather had been very pleasant recently and the area was being well used. Suitable sun protection was available. One individual that had previously been nursed on a mattress on the floor for safety reasons was now been nursed at nighttime on a specialist low bed. The Old Vicarage Nursing Home DS0000022358.V368992.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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and skill mix of the staff meet the needs of people who use the service. People are in safe hands and protected by the home’s recruitment policies and procedures. Staff are trained and competent to do their jobs. EVIDENCE: Staffing levels remain the same for the three shifts as they have at previous at our visits, which are: Five staff in a morning, Four staff in an afternoon, Three staff during the night. These numbers include one nurse throughout the 24-hour period. At the time of our inspection there were 25 people using the service. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 20 the service. We saw staff rota’s and from our observations and discussions staffing numbers are adequate to meet the needs of the current group and number of people. One new admission was planned for the following week and enquiries were being made for another person. The service is presently completing some new staff appointments and Protection of Vulnerable Adults checks were being made. There is only minimal use of agency staff. It was identified at the last inspection that recruitment procedures should be strengthened. New procedures are now in place. A new database has been established and new application form and interview format put into place. A sample of staff files was seen. It was evident that the new files were in line with that information required listed in schedule 2 of the Regulations. One relative spoken to said, “The staff were very professional and caring. They are knowledgeable about the people who live in the home and have some ‘nice’ times with them.” The training matrix was evidenced and the training plans for the next few months. The following training had been completed for most staff: • Protection of Vulnerable Adults update • First Aid training • Food hygiene • Manual handling (Trainer on site) • Palliative care • Dementia awareness • Infection control – Hand washing The manager had completed a Health and Safety course, which she uses to train the staff on such things as safe use of cot sides and wheelchairs. Staff meetings are held and minutes kept. The staff was happy to chat to us and discuss the management of the home and care of the people who use the service. Some issues had been raised with the manager, which staff told us the manager had responded well to. The staff said they were ‘settled at work and felt they were well trained’. One lady spoken to for some time said she watches the staff and they are kind to all the people in the home and each other. She said her family always say how nice the staff are. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 21 The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed by the manager who is fit to be in charge and of good character. The service is run in the best interests of the people who use it and their financial interests are safeguarded. The health, safety and welfare of people who use the service and the staff are promoted and protected. EVIDENCE: The Manager is a registered nurse and has the required experience to run the home. She has now completed her Registered Managers Award and is The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 23 awaiting her certificate. The Manager has again made considerable progress in many areas since our last visit. A visiting relative commented on the positive changes made in the home by the Manager and how the atmosphere in the home was now pleasant and relaxed. The relaxed and open atmosphere was evident during this inspection. Staff again made a valuable contribution to the inspection process. A Quality Assurance system has commenced with surveys completed by relatives and some people who use the service. The manager has introduced Quality Assurance audits for the kitchen, laundry, domestics and the home. She is keen to use these as a means of service improvement. The plans to introduce resident and relatives meetings have now commenced. The improvement in record keeping over the past year has continued including more detailed care plans, recording of daily activities, staff recruitment and selection, social histories and details of preferred lifestyles and choice. We checked money belonging to people use the service that is held in safekeeping. We found this to be correct. The manager has responsibility for the health and safety issues, the nurses and carers support her with this. We saw that risk assessments are in place for people who use the service to ensure their safety is maintained at all times. Fire risk assessments for the service are completed, but further work is required including the fire evacuation plan, which individually describes the action to take should the building need to be evacuated. We found that equipment is serviced and checked as required and water temperatures are tested and recorded. Three care staff are trained in first aid and more staff will be trained in the next planned session. We saw that accident records are recorded correctly. One lady had recently been having unexplained falls and there was evidence that the doctor had reviewed this person’s condition and medication and she was being monitored to try and prevent more falls and to keep her safe. The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP1 OP15 OP30 Good Practice Recommendations The Statement of Purpose and Service User Guide are to be further personalised to assist the people who use the service to make an informed choice about where to live. The teatime meals menu is to be made available for people who use the service to make a choice. Picture menus are to be introduced to assist them. Staff induction should be completed in a timely manner of 6 weeks to ensure they are working to the policies and procedures in the home and are safe to work with the people who use the service. The manager must ensure that adequate arrangements are made to evacuate people who use the service should the need arise. This document must list the names of the people who live in the home and the way in which they will be removed from the building. Once complete this information should be used as part of the fire training for the staff. DS0000022358.V368992.R01.S.doc Version 5.2 Page 26 4 OP38 The Old Vicarage Nursing Home The Old Vicarage Nursing Home DS0000022358.V368992.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 The Old Vicarage Nursing Home DS0000022358.V368992.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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