Care Home: Vicarage Farm Nursing Home

What the care home does well Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Staff were observed to interact with the residents in a caring and professional manner. The home has a visiting policy and visiting is encouraged. Relatives and visitors spoken with during the course of the inspection commented that they are always made to feel welcome. Information regarding advocacy services is available. The meal provision in the home is good and residents are offered choices to meet individual preferences. Complaints and safeguarding are well managed. The home was clean and fresh throughout. Systems are in place for the management of infection control. The home has an ongoing programme of training for staff to meet the needs of the residents. Over 50% of care staff have attained their NVQ level 2 training or equivalent. Residents monies are well managed with all documentation in place. Health and safety is being well managed. The Expert by Experience commented that `the staff were welcoming and cheerful and that the atmosphere was warm and friendly`. What has improved since the last inspection? Since the last inspection there has been a marked improvement in the formulation and review of the service user plans. Residents and their representatives now have input into the service user plans. All assessments viewed were accurate and up to date. Wound care documentation was comprehensive and up to date. Evidence of continence management had been Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 included in the service user plan. The home was using the correct lancing devices for blood glucose monitoring on both floors. There had been an overall improvement in the medication management in the home. The staff had worked hard to ensure that the residents wishes in the event of health deterioration and care in their final days had been discussed and recorded. There has been some work undertaken on improving the environment for the residents however this needs to be further progressed and the environment throughout brought up to a good standard. Changes have been made to the smoking provision in the home and residents now smoke outside in the courtyard area. No shortfalls in staffing had been identified at this inspection and we did not receive any comments that the home was short staffed. Staff records were being well maintained and the shortfalls identified at the inspection had been promptly addressed. The home has a good system for quality assurance, which is being followed. It is acknowledged that staff and the management team have worked hard towards meeting the requirements of the last inspection report. What the care home could do better: We observed that some activities were taking place at the home these were somewhat limited. The activities provision in the home must be improved to ensure that all residents individual needs, interests and preferences are accommodated. Whilst there has been some improvements in the environment lack of progress in the areas of lighting provision and replacement of carpeting is disappointing. Southern Cross must promptly address shortfalls in the environment and ensure that sufficient funding is available for this work to be undertaken. CARE HOMES FOR OLDER PEOPLE Vicarage Farm Nursing Home 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 10:00 20th April 2009 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vicarage Farm Nursing Home Address 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8577 4000 020 8572 1221 vicaragefarm@schealthcare.co.uk Southern Cross Healthcare (Management) Limited Care Home 62 Category(ies) of Dementia (35), Mental disorder, excluding registration, with number learning disability or dementia (5), Old age, not of places falling within any other category (27) Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 27) Dementia - Code DE (maximum number of places: 35) Mental Disorder, excluding learning disability or dementia - Code MD (of the following age range: over the age of 50) (maximum number of places: 5) The maximum number of service users who can be accommodated is: 62 28th April 2008 2. Date of last inspection Brief Description of the Service: The home is situated in a residential area of Hounslow. It is set back from the road and has good car parking facilities. There are local shops within walking distance. There are accessible local bus routes and the home is within ten minutes walk of Hounslow West underground station. The home is set on two floors. The ground floor provides accommodation for twenty-seven residents and the first floor provides accommodation for thirtyfive residents. The home provides nursing care to older people with a range of care needs to include dementia, mental disorder and physical disability. There are fifty-four single rooms and four shared rooms in the home. There is a well-maintained central courtyard area with furniture suitable for residents and their visitors. The fees range from £630 to £900 per week. Vicarage Farm Nursing Home DS0000010962.V374641.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 as part of the regulatory process. A total of 18 hours was spent on the inspection process, and was carried out by 2 Inspectors plus an Expert by Experience. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 8 residents, 14 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home has also been used to inform this report. No comment cards were returned by residents healthcare professionals or staff at this inspection. It must be noted that it is sometimes difficult to ascertain the views of residents with dementia care needs. What the service does well: What has improved since the last inspection? Since the last inspection there has been a marked improvement in the formulation and review of the service user plans. Residents and their representatives now have input into the service user plans. All assessments viewed were accurate and up to date. Wound care documentation was comprehensive and up to date. Evidence of continence management had been Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 6 included in the service user plan. The home was using the correct lancing devices for blood glucose monitoring on both floors. There had been an overall improvement in the medication management in the home. The staff had worked hard to ensure that the residents wishes in the event of health deterioration and care in their final days had been discussed and recorded. There has been some work undertaken on improving the environment for the residents however this needs to be further progressed and the environment throughout brought up to a good standard. Changes have been made to the smoking provision in the home and residents now smoke outside in the courtyard area. No shortfalls in staffing had been identified at this inspection and we did not receive any comments that the home was short staffed. Staff records were being well maintained and the shortfalls identified at the inspection had been promptly addressed. The home has a good system for quality assurance, which is being followed. It is acknowledged that staff and the management team have worked hard towards meeting the requirements of the last inspection report. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. The home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document, which provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Copies of assessments undertaken by Social Services and the Primary Care Trust, plus discharge information sent by the hospitals was also available. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is well completed and provides staff with the information to meet the needs of each resident. Medications management at the home is good, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The wishes of residents and their families in respect of end of life care is discussed and recorded, thus ensuring that these can be respected and met. EVIDENCE: We viewed 4 service user plans. These were well completed and up to date, providing a good picture of each resident and how their identified needs are to be met. Risk assessments for falls and other identified risks were in place, and there was evidence that documentation in respect of falls had been reviewed and updated following any falls. Service user plan documentation had been updated monthly and also when there was any significant change in a residents condition. There was evidence of input from residents representatives into the service user plans and also with the 6 monthly resident reviews that are carried out and recorded. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 10 We viewed some of the wound care documentation. Pressure sore risk assessments were in place and were up to date. Photographs of wounds had been taken and also body mapping had been carried out to identify any wounds or bruising noted. Care plans had been formulated for each wound and clear records of the dressing regime and dressing changes were available, and evidenced the progress of each wound. Pressure relieving equipment was in use and had been recorded on the care plans. We discussed recording the actual make of pressure relieving mattress in use to clearly identify the level of risk being provided for in each case, and the Manager said that this would be addressed. The Community Matron was involved in the assessment and review of any pressure sore concerns identified by the home. Moving & handling assessments were in place and the equipment to be used for each resident had been identified along with the number of staff to attend each resident. Continence assessments were in place, with one seen requiring a staff signature and date of completion. Information regarding continence regimes was available, but not always in a care plan specifically for continence care, and this was discussed with the registered nurses. Nutritional assessments were in place, and there was evidence of any concerns of low weight being reported to the GP and nutritional supplements being prescribed. For residents being fed via a percutaneous endoscopic gastrostomy (PEG) tube, clear feeding regimes as prescribed by the dietician were in place and being followed. Residents are weighed monthly unless a significant weight issue is identified, and then more frequent weights can be carried out. Where it is not possible to weigh a resident due to their condition, this is recorded, to include the reason why. Bedrail risk assessments were in place and consents for the use of bedrails had been signed. There was evidence of input from healthcare professionals, and the home currently has several GPs who provide medical care to residents. Chiropody, optical and dental input was also recorded. We sampled the medication records and management. Lists of specimen staff signatures and initials were available. Front sheets for each resident were comprehensive, to include their name, photograph, allergies and other relevant information. For the majority of medications the home uses a monitored dosage system (MDS) on a 28 day cycle, and we viewed the morning medications for 10 residents and stocks were correct. Receipts and administration of medications had been recorded on the medication administration records (MAR) viewed, to include medications received midcycle. Where a medication had been omitted, this had been clearly recorded with the reason for omission. Liquid medications had been dated when opened. For medications to given via a PEG tube this had not always been clearly identified on the MAR, and this was to be addressed. The air conditioning unit for the ground floor clinic room was out of order, and had been for 4 months. The Manager explained that parts could not be obtained due to the age of the equipment. As a result the room temperatures were on occasion over 25° centigrade. The medication fridge was also not functioning properly, and we were told that the 2 issues were linked. The air conditioning and fridge were Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 11 functioning properly on the first floor and medications requiring refrigeration were all being stored in the first floor fridge. The Manager has since confirmed that a new air conditioning unit has been placed in the ground floor medications room. Controlled drugs were being correctly stored and the records were up to date. Full signatures had been used in the controlled drugs register on most occasions, and the registered nurse said that she would ensure all staff were reminded to use a full signature in future. Controlled drug stock checks are carried out at each handover and signed for. The home did have single use lancets available for use for blood glucose monitoring. They also had some of the lancing devices for individual use that are not approved for use in a care home setting, and this was addressed by the staff at the time of inspection, to include discussion with a GP on this matter. Overall medications are being well managed at the home, with the need to ensure equipment for maintaining safe temperatures for the storage of medications needing to be monitored. A requirement is made for this under Standard 38. Staff were seen caring for residents in a gentle and professional manner, respecting their dignity. There was some good interaction overheard between staff and residents and there was a good atmosphere in the home. Residents clothing had been labelled discreetly for identification purposes. Some bedrooms had been personalised, however more work was needed on this and the Manager had already identified this shortfall. Residents looked well cared for and were dressed to reflect individuality. There was evidence that discussion had taken place regarding the wishes of residents and their families in respect of health deterioration and end of life care, and this information had been recorded. It was clear that this information could be reviewed at any time should the need arise. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides some activities that are advertised, with more work to be done in the implementation of activities for all residents, to fully meet all residents needs in this area. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the residents rights, choices and opinions are heard and respected. The food provision in the home is good, offering variety and choice, to meet the resident’s individual needs and preferences. EVIDENCE: The home has an activities co-ordinator and the Expert by Experience spoke with her. Activities are arranged, however the activities programme is quite basic and more needs to be done to expand the programme of activities and to incorporate activities into the daily routine for each resident, dependent on their interests and abilities. The activities co-ordinator does ascertain information regarding individuals’ interests, and also keeps a record of activities undertaken by each resident. More information was available in the Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 13 care plans in respect of peoples’ interests, with further work to be progressed. The Manager was clear that a more comprehensive approach to activities is required to make this an integrated part of the daily life of the home for each resident. Records of activities in the residents care plans were, in some cases, quite sporadic. The activities co-ordinator has undertaken the Alzheimer’s Society ‘Yesterday, Today and Tomorrow’ training, which looks at activities as part of daily life, and further training in activity provision for older people was discussed. The home has an open visiting policy and visiting is encouraged. Visitors said that they are made welcome at the home and that any issues are reported to the residents representative. Information regarding contact details for advocacy services is on display in the home. This includes information on accessing financial information. We viewed the kitchen and this was clean and tidy, with all records up to date. There was evidence that residents had been offered a choice of meals and their choices had been recorded. The menus on display in the reception area did not reflect the meal being offered for the day, and this was corrected at the time of inspection. The Manager explained that Southern Cross were in the process of reviewing the nutritional programme it had introduced, in order to ensure that as well as considering the nutritional value of meals, the wishes of the residents were being fully taken into account when formulating the menus. The Expert by Experience viewed the lunchtime meal provision. Staff were available to assist residents with their meals, however in some instances residents who could feed themselves with encouragement were not receiving supervision, and therefore meals were being left to go cold. Another supervision issue was identified in relation to the feeding of a resident and these issues were discussed with the Manager. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust systems in place for the management of complaints and for adult protection concerns, thus safeguarding residents. EVIDENCE: The home has a clear complaints procedure and all concerns and complaints are documented and addressed. 4 complaints had been recorded since the last inspection. Documentation for complaints was comprehensive and showed a clear progress of each complaint and how it had been addressed. The home has policies and procedures in place for the protection of vulnerable adults. We spoke with staff and they knew to report any concerns. We identified that some terminology was not always understood by all staff, and the Manager had already identified the need to source English language training for some staff, and also to incorporate this as part of the interview processes. There have two safeguarding allegations since the last inspection, which were appropriately reported and investigated. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21,22, 24,25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being maintained and there is evidence of some redecoration and refurbishment taking place. This needs to be further extended to cover all areas of the home to ensure that residents have a homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: We carried out a tour of the home. There was evidence of some redecoration and refurbishment, mainly in the sitting room areas, plus the flooring had been replaced in some bedrooms. We were informed that an environmental audit had been undertaken and a plan developed for the redecoration and refurbishment of the home. However there was no change in the first floor corridor carpet and no improvement in the standard of lighting in the home. We were informed that the finances for the replacing of the carpet had been Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 16 approved, and the home was awaiting the outcome of the review of the lighting provision. We had not been informed of the delays in actioning these requirements from the last inspection. We were also informed that issues had arisen with subsidence in the rear garden and pot holes appearing in the driveway. The driveway had been repaired and work was in progress in addressing the subsidence. Following the inspection we were contacted by the Operations Manager for the home who informed us that they had received a quotation for the lighting work and that this would be completed as a matter of priority. Also, that carpets had been ordered for the first floor corridor and that they were waiting for a fitting date from the contractors. The Expert by Experience commented that ‘some of the bedrooms were somewhat stark, impersonal and dingy due to the low light level. However some of the residents did have personalised rooms with their own pictures’. We were informed that all equipment at the home was in working order on the day of the inspection. Since the last inspection residents can only smoke outside of the home. Plans are in place to have a covered area in the rear garden for all residents who smoke. Some of the bathrooms were being used as storage areas and we were told that they are no longer being used as bathrooms. This needs to be clearly identified on the doors We viewed the laundry facilities and these were clean and tidy. There are 2 washing machines with wash programmes for infection control. There are 2 tumble dryers. Infection control and good practice information posters were on display in the laundry. Residents clothing was appropriately labelled. Infection control procedures are in place and are being followed. Protective clothing to include gloves and aprons is available in the home and were seen being used appropriately. The home was clean and fresh throughout. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents can be met. Systems for vetting and recruitment practices are in place and protect residents. Shortfalls found should be easy to address. There is an ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: At the time of inspection the home was appropriately staffed to meet the needs of the residents. We were informed that due to the number of empty beds at the home staffing had been reduced on the ground floor nursing unit by one member of staff. The Manager said that this would be reviewed in line with new admissions to the home and dependency levels of the residents. There were sufficient ancillary staff to meet the needs of the home. The AQAA evidenced that over 50 of the care staff are qualified to NVQ in care level 2 or 3 and several more staff are currently undertaking this training. We viewed 2 sets of staff employment records. With the exception of a photograph the records contained the information required under Schedule 2 of the Care Home Regulations 2001. We noted that for trained nurses the home had taken a copy of the Nursing and Midwifery Council registration card. However the details of the nurses had not been verified by the home. We were Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 18 informed that this had been completed the day following the inspection and written confirmation had been sent to the Commission. Southern Cross Healthcare Services Limited has an induction programme based on the Skills for Care common induction standards. There was evidence that training in topics relevant to the diagnoses and needs of the residents had taken place. This included The Alzheimer’s Society ‘Yesterday, Today and Tomorrow’ training. The training matrix evidenced that some staff had undertaken training in dementia awareness, challenging behaviour, medication management and care planning. Staff spoken with also confirmed that they had attended several training courses. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the experience to manage the home, and is open and approachable. Systems for quality assurance are in place and provide an ongoing process of management and practice review. Resident’s monies are being managed and securely stored. Systems for the management of health and safety are in place thus ensuring that the residents, staff and visitors are protected. EVIDENCE: The Manager has been in post since October 2008. He is a first level nurse qualified in both general nursing and mental illness nursing. He has a BA in Education and has completed his Diploma in Management Studies. He has several years experience of nursing the elderly and has extensive management experience. The Manager described his management style as ‘hands on, open Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 20 door and supportive’. Staff spoken with confirmed that the Manager was supportive and attended both floors several times throughout the day. There are clear lines of accountability within the home. Southern Cross Healthcare Services Limited has a quality assurance system in place for each home. There is a monthly Managers audit that covers all aspects of the home and the Operations Manager does a validation audit every 2 months from which an action plan is produced. Audits to include medication, care planning and wound management were viewed. We were informed that residents and relatives satisfaction surveys had been undertaken and that the Manager was in the process of collating the results of these surveys. Daily handover meetings are held and any concerns raised are addressed at this meeting. There was some evidence of staff and heads of department meetings taking place. Regulation 26 unannounced visits were taking place monthly and reports of these visits were available at the inspection. The Manager had already held one residents and relatives meeting, with evidence of future meetings already having been arranged. We noted that the Manager also holds a Managers surgery weekly for those relatives who wish to discuss any concerns/issues with the Manager. We sampled records for residents’ personal monies held on their behalf by the home. The financial records viewed were being well maintained with receipts and records for income and expenditure available and up to date. The administrator informed us that the company undertakes an annual financial audit and that the home was due an audit in the summer. Maintenance and servicing records were sampled and those viewed were up to date. The fire risk assessment had been updated in June 2008. Regular fire drills and tests were being undertaken to cover both day and night staff. We viewed the staff training matrix and it was evident from this that not all staff had received training in health and safety topics to include moving and handling. The Manager said that he was aware of this and training in these areas was being arranged. Risk assessments for safe working practices were available. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 21 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 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 3 X 3 2 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 2 Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 22 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 OP12 Regulation 16(m)(n) Requirement Further improvements must be made in the provision of activities for all residents living at the home. The activities provision must be inclusive of all residents. Further work must be undertaken in improving the quality of the environment, this is to ensure that the residents have a safe and well maintained home to live in. The lighting throughout the home must be replaced to ensure that the residents have appropriate levels of lighting to meet their needs. All equipment must be maintained in working order and where it can no longer be repaired, it must be replaced without delay. Timescale for action 01/07/09 2. OP19 23(2)(b) & (d) 01/07/09 3. OP25 23(2)(p) 01/08/09 4. OP38 23(2)(c) 01/06/09 Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 24 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk © This report is copyright Care Quality Commission (CQC) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CQC. Vicarage Farm Nursing Home DS0000010962.V374641.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!