Care Home: The Vicarage Residential Care Home

What the care home does well The service works well with the people living in the home and their relatives. There is an emphasis on listening to the views of the people using the service, and involving them in the development of the service. This was very apparent from the views we obtained from people using the service. Comments included: The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 The manager and staff and owner have always got time to listen to the people”. “The home is really run in the best interest of the people living here”. The service has prioritised health and safety, and the general refurbishment of the home. We received many comments about the improvement of the environment. People told us that it was a pleasure to visit here, that the hygiene and cleanliness were very good and that they had seen positive improvement in the decoration of the home and in furnishing and fittings. People spoke highly of the management and staff team and said that they were approachable and made them feel welcome into the home. People told us: “The staff are very good, very helpful. I can tell them if there’s a problem”. “I fell confident in approaching the manager, the owner and staff with anything of concern”. “The manager and owner are very visible and have made positive changes here”. “The staff are marvellous, fantastic, you can see the improvements in the past months. They are very approachable and you can talk to them about anything”. There was evidence to show that the management team are working hard to develop the staff training programme, and they already provide support to staff and have systems in place to identify training needs. The information in the AQAA showed us that this is a service that is committed to developing the home in a way that serves the best interests of the people living there. What has improved since the last inspection? This is the first inspection of this service since it was registered as a new service.The Vicarage Residential Care HomeDS0000073059.V378883.R01.S.docVersion 5.2 What the care home could do better: The service needs to ensure that call systems are checked regularly, and that they are accessible to people. This means that the safety and well being of people in the home is promoted and that they can use call systems appropriately when required. Care plan recordings need to be linked in with care plans so that staff can easily reference information when providing care and support. This means that people in the home will receive the right care in a safe and appropriate way. Daily recording need to be linked to the care plan to demonstrate and evidence that care and support has been provided as detailed in the care plan. Some consideration could be given to the layout of one of the communal rooms so that a ‘homely and intimate’ environment is provided for the people who live there. Key inspection report CARE HOMES FOR OLDER PEOPLE The Vicarage Residential Care Home 109 Audenshaw Road Audenshaw Tameside M34 5NI Lead Inspector Ann Connolly Key Unannounced Inspection 11th January 2010 11:15 DS0000073059.V378883.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Vicarage Residential Care Home Address 109 Audenshaw Road Audenshaw Tameside M34 5NI 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) 0161 301 4766 0161 301 4766 Clarkson House Residential Care Home Limited Care Home 30 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (30) of places The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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 Old age, not falling within any other category - Code OP Dementia Code DE The maximum number of service users who can be accommodated is: 30 Date of last inspection This is the first inspection of this service Brief Description of the Service: The Vicarage is a large Victorian property that has been extended and adapted into a residential care home. The house is set back from the main road and is situated on the main transport route which connects Manchester City Centre, Droylsden and Ashton-u-Lyne. It is within easy access to public transport links. It offers accommodation to 30 older people in mainly single rooms, some with en suite facilities. The accommodation consists of a large separate dining room, and two large spacious lounge areas one with a second dining area. The home is equipped with ramps and specially adapted bathrooms. A passenger lift provides access to all floors. There is a separate smoking room. The large spacious hall and corridor areas make it easily accessible for wheelchair users. There are pleasant garden areas and ample parking is provided to the front of the building. Fees for this service range from £398.11 to £405.11 per week. The Vicarage Residential Care Home DS0000073059.V378883.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 care home is two star good service. This is the first inspection of this service since registration. This was a key inspection that included a visit to the home. The manager was not told beforehand that we were coming to inspect, this is called an unannounced inspection. This inspection looked at all the key standards and included a review of all available information received by the Commission about the home. During the visit, a selection of records, care plans, polices and procedures were looked at. Discussion took place with the manager, the provider, staff working in the home and some relatives who were visiting. We spoke with people living in the home to find out what they felt about the service and how staff supported them. A tour of the building took place and people living in the home were asked for their comments and views about the environment. Before the inspection we asked the manager of the home to complete a form called the Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well and what they needed to do better. The information provided on this occasion showed us that this was an organisation that was committed to the ongoing development of the service. Surveys were sent out to people living in the home, and there was a good response in the returned surveys. The comments in the surveys were very positive about the quality of the service and the staff working in the home. This reflected the findings on the day of the inspection visit. The service has good systems in place for managing complaints. Since registration of the service they have received a total of 9 complaints and all were responded to within the stated timescale. The Commission has not received any recent complaints about this service. What the service does well: The service works well with the people living in the home and their relatives. There is an emphasis on listening to the views of the people using the service, and involving them in the development of the service. This was very apparent from the views we obtained from people using the service. Comments included: The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 Page 6 The manager and staff and owner have always got time to listen to the people”. “The home is really run in the best interest of the people living here”. The service has prioritised health and safety, and the general refurbishment of the home. We received many comments about the improvement of the environment. People told us that it was a pleasure to visit here, that the hygiene and cleanliness were very good and that they had seen positive improvement in the decoration of the home and in furnishing and fittings. People spoke highly of the management and staff team and said that they were approachable and made them feel welcome into the home. People told us: “The staff are very good, very helpful. I can tell them if there’s a problem”. “I fell confident in approaching the manager, the owner and staff with anything of concern”. “The manager and owner are very visible and have made positive changes here”. “The staff are marvellous, fantastic, you can see the improvements in the past months. They are very approachable and you can talk to them about anything”. There was evidence to show that the management team are working hard to develop the staff training programme, and they already provide support to staff and have systems in place to identify training needs. The information in the AQAA showed us that this is a service that is committed to developing the home in a way that serves the best interests of the people living there. What has improved since the last inspection? This is the first inspection of this service since it was registered as a new service. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Vicarage Residential Care Home DS0000073059.V378883.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 Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual care needs are assessed to ensure that staff are able to confirm that they can meet identified needs in an appropriate way. EVIDENCE: A selection of care plans were looked at. All files that were selected included a detailed assessment of care needs. The assessment from the placing authority was used in the assessment process and included some assessments completed by a senior member of staff from the home. Detailed risk assessments were in place, with information for staff on how to manage and minimise risk. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 10 The pre admission assessment looked at all aspects of health and social care needs and showed us that consultation had taken place with the individual person and their family about every day lifestyle preferences. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with dignity and respect and their health, personal and social care needs are taken seriously. EVIDENCE: All care plans were under the process of review and had been re-organised with a new index system. There was a written plan of care for each individual person in the home. The information in the care plans looked at identified care needs and provided staff with the relevant information to help them in supporting people appropriately. There were some examples where changes in care needs had been identified, and the care plan had been amended appropriately to reflect the changes. This means that staff are kept fully updated so that they support people in a safe way. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 12 The information in the care plans included all aspects of health and social care. There were clear records to show that people in the home were supported to access healthcare services and we saw examples where staff supported people to attend appointments. We spoke to some relatives of the people living in the home. One person told us that they felt fully consulted and involved with care planning. This person said, “They have always consulted with me, and recently they kept an eye on diet intake when weight loss was a problem. I feel they meet care needs really well”. Other people were positive about the way in which staff responded to meeting care needs. Comments included: “The owner and staff really do put residents first”. “The staff are very good and helpful, they listen to me. I can tell them if there’s a problem”. “The owner and staff have got time to listen to the people living here”. The daily recording were kept in a separate folder from the care plan. When we looked at some of these, the recordings were not always relevant to the care plan and they didn’t consistently show how staff had implemented the care plan. The manager was aware that recording needed to be more specific and make reference to how care plans had been met. It was recommended that care plan recording are kept with each individual care plan so that staff can quickly reference to the section that provides the specific information on how individual needs are to be met. Policies and procedures were in place for the safe handling of medication. A sample of medication was looked at. Records were well maintained and medication administration records (MAR) were filled in appropriately by staff responsible for the administration of medication. Systems were in place to carry out audits and monitoring of medication practices in the home, this was being developed further by the manager to improve recording systems to evidence the process. During this visit staff were seen engaging in meaningful conversation with the people living in the home. The atmosphere was relaxed, and people were seen making positive use of all parts of the communal space. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive the support they need to live their chosen lifestyle. EVIDENCE: During this visit there were numerous visitors to the home. Most of these were relatives of the people living in the home. The visitors were seen to be made welcome by the staff team, and during the day the atmosphere seemed relaxed, and people enjoyed the day to day business of people coming and going. Visitors we spoke to told us that they were always made welcome by the staff team and manager. This was evidenced during the day when visitors popped into the office to see the manager, there was an open transparent approach used by the manager who has an ‘open door’ policy, and relatives clearly felt comfortable and at ease in calling in to the office. During the day there was evidence of activities going on. There was an activity programme in place which included art and craft, beauty and manicure, games The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 14 and outings. There is an appointed activities organiser who has allocated time of three days per week to organise activities. The manager and provider told us that this was under review and that it was hoped that these hours could be extended. This reflects the statement in the AQAA where it states that the service intends to improve the activities programme over the next 12 months and increase the number of outings available to people living in the home. The activities organiser was very positive about developing the activities programme and had several creative and innovative ideas that she hoped to develop. There was an emphasis to using a person centred approach, and working with individuals and their relatives to find the most appropriate activity and approach and to listening to people about their individual lifestyle preferences. The meal in the home was sampled and was of a very good standard. The meals are prepared daily using fresh produce and are home cooked. During this visit the menu consisted of home made meat and potato pie, fruit pie and custard, for tea the menu was a choice of scrambled eggs on toast or chip muffin, cheese cake, yogurts, fresh fruit. People in the home told us that they enjoyed the meals served, and confirmed that they were choices were available, although it was noted that these were not recorded on the menu. The cook told us that staff consulted with people in the home on a daily basis to discuss their preferences and menu choice. During discussions with the cook and the manager, it was agreed that more consideration would be given to making sure that the choices available to people were recorded, and that people would be shown the alternatives available. The mealtime occasion was pleasant and relaxing. Tables were set in small groups in a pleasant dining room, and other dining areas were available in the main lounge area. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are handled well and taken seriously ensuring people feel listened to. EVIDENCE: Policies and procedures are in place to ensure the protection of the people living in the home. The complaints procedure was included in the service user guide which informs people that all complaints will be responded to within ten working days. A large number of relatives, visitors and people living in the home were spoken to during this visit. All of them told us that they felt confident in raising concerns to the manager or the staff team. Comments included: “I feel at ease with this home and I feel I can approach the manager with any concerns”. “Staff are very good and very helpful. I can tell them if there’s a problem”. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 16 During this visit, it was noticeable that many relatives consistently told us that the home was ‘run for the benefit of the residents’. One person said, “The staff and manager have always got time to listen to the people”. A number of staff were spoken to during the day, and they were able to demonstrate a good understanding of issues around abuse and safeguarding procedures. During this visit, the provider and manager told us that training was going to be prioritised in the next twelve months including safeguarding training. There was evidence during this visit to show that training records were being updated so that the management team could monitor and identified training needs. Staff receive training and supervision to that they are familiar with important policies and procedures. Information in the AQAA stated that there had been nine complaints received by the service and that all of these had been responded to within the timescales detailed in the complaints procedure. The Commission has not received any recent complaints about this service. There have been no recent safeguarding referrals. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Vicarage provides a safe and comfortable home that is well maintained and decorated to a good standard. EVIDENCE: During this visit a tour of the building took place. There were good standards of hygiene and cleanliness throughout the building and furnishings and fittings were of a good standard. The building had large spacious lounge and communal areas that benefited from large open aspect window and patio doors which brought light into the rooms. The large lounge with dining area was well presented, with pleasant furnishings, but the layout looked institutional, with chairs located against walls round most of the room. Dining tables were The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 18 located in the centre of the room. It was recommended that some thought should be given to considering an alternative layout with small group sitting areas which may provide a more ‘homely’ feel. This should be done in consultation with people living in the home, to seek their views and preferences. Throughout this visit, it was noted that good use was made of the large communal space, and staff supported people in the home to access all parts of the building. It was noted that the dining room had a latch fitted to the door which may prevent some people from going and sitting in the dining room. It is recommended that this is removed so that people have access to all rooms in the building. This building benefits from large wide hallways and corridors which were brightly decorated and well lit. This makes moving around the home easy for the people living there. Some bedrooms were looked at and it was evident that people in the home were encouraged to bring their own possessions and personalise their rooms. It was noted that a number of rooms did not have the cord bell attachment in place. A requirement has been made to ensure that all rooms have an accessible alarm cord in place to ensure that people can use them when needed. This process was commenced at the time of this visit, and some cords were fitted. There was evidence of ongoing improvements and refurbishment to the home, many areas had be re-decorated and refurbished with new bathrooms and shower room being installed on the ground floor. These installations were of a high quality with a wet room facility. People who were spoken to were highly complimentary about the improvements made to the building. Comments included: “I’m really impressed with the changes- everything is done for the residents”. “It’s much better with the new owner, It’s cleaner and better decorated”. “You can see so many improvements have taken place, it’s a pleasure to visit”. Information in the AQAA provided evidence that the manager had prioritised infection control. Facilities in the home included pleasant outdoor spaces for people to enjoy in the warmer weather. The manager told us that systems were in place to monitor health and safety and a handyman was employed to ensure that the building was maintained at all times. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 19 The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are supported by a well trained staff team who have gone through a thorough recruitment process, so their needs are met and they are protected from poor practice. EVIDENCE: During this visit there were sufficient staff on duty to meet the needs of the people living in the home. The staff were seen to participate in meaningful conversations with the people living in the home, and were observed supporting people in a caring and sensitive manner which promoted the privacy and dignity for the individual. The feedback from people living in the home and relatives was very positive about the support they received from staff. Comments included: “The staff are marvellous- we can see improvements over the past months, they are very approachable and you can talk to them about anything”. “The staff, manager and owner have always got time to speak to the residents”. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 21 “The staff are friendly and they provide me with updates on how things are going”. “Staff are very good and very helpful”. A sample of staff files were looked at and all of them contained appropriate checks and relevant documentation. This home is under new management, and information in the AQAA informs us that the management team have focused on building up relationships with the existing team and appointing new team members. The information in the AQAA provides confirmation that training will be prioritised in the next 12 months, and that there are plans to draw up a new personal development plan for each individual member of staff, and address any identified training needs. At the time of this visit, the manager was in the process of developing a training matrix, and was able to show us that they are in the process of establishing an extensive training programme. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being run in the best interests of the people who live there and their welfare is promoted and protected. EVIDENCE: The manager is new to the post but has several years senior experience of working in the organisation. The provider told us that they were in the process of submitting an application for the manager of the home to become the registered manager. Discussion with the manager throughout the day about the home’s management systems provided evidence that she was committed The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 23 to making sure that staff have the right support, supervision and training. This means that people livening in the home will be confident that staff have the right skills to meet their assessed needs. Staff supervision and appraisal records were in place to show that they were in receipt of supervision. The manager told us this was an area she proposed to develop further, and link supervision into the personal development plans for individual staff. Staff who were spoken to told us that they could approach the manager at any time and that they felt well supported. People living in the home, staff and relative spoke highly of the management stule and said that they felt the manager and the provider were very approachable and always visible. We received numerous comments about the way the management had developed practice in the home for the benefit of the people living there. Many people said, “The home is run for the residents”. There was documentary evidence and information in the AQAA to show that the service routinely carried out checks in relation to health and safety. This means people in the home can be confident that their health and safety is prioritised by the management. There was documentary evidence to show that people living in the home were regularly consulted, and that their views and opinions influenced the way the home was run. There were examples where individuals had expressed a preference regarding furnishings in their bedrooms, and evidence to show that an appropriate response and action had been taken in regards to this. The manager outlined plans to develop the auditing systems in the home which included audit checks on medication, care planning and quality control. There was evidence through discussion with the manager and information in the AQAA to show that this was a service that was committed to ongoing improvements to improve the service quality for the people living in the home. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 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 x 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 x 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation Requirement Timescale for action 31/01/10 23 (2) ( c) All bedrooms must have an accessible alarm cord in place so that people in the home can reach them, and so that their safety and well being is promoted. 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 Recording should be kept with each individual care plan so that staff can quickly reference to the section that provides the specific information on how individual needs are to be met. 2 OP19 Consideration should be given to improve the layout of lounge areas to provide a homely environment, and people living in the home should be consulted regarding their preferences regarding layout. The Vicarage Residential Care Home DS0000073059.V378883.R01.S.doc Version 5.3 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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