Inspection on 16/09/05 for 30 Vicarage Road

This inspection was carried out on 16th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

30 Vicarage Road 13/11/08

30 Vicarage Road 06/12/06

30 Vicarage Road 26/01/06

30 Vicarage Road 01/03/05

30 Vicarage Road 21/09/04

30 Vicarage Road 25/11/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 30 Vicarage Road 30 Vicarage Road Rugby Warwickshire CV22 7AJ Lead Inspector Justine Poulton Unannounced Inspection 16th September 2005 08:40 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 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 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 30 Vicarage Road Address 30 Vicarage Road Rugby Warwickshire CV22 7AJ 01788 547781 01788 573410 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) RMH Homes Ms Jane Felicity Bacon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: 30 Vicarage Road is a large town house in a residential area close to the town centre of Rugby. It provides residential care for six people with learning disabilities and low care needs. There is usually one member of staff on duty with residents. The house is staffed the majority of the time when residents are at home. Day services are not routinely provided at the house but residents can have days at home if they wish. The ground floor consists of two lounges and a large dining/ kitchen area. There are two upper floors, each with a bathroom. The six single bedrooms and one sleep in room for staff are divided between the first and second floors of the house. There is a courtyard at the rear and a range of outhouses; one of which is used for pottery classes by residents from other houses in the scheme, on a regular basis. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday and was carried out from 8:40am until 12:40pm. The manager, residents and staff co-operated fully with the inspection. A total of 16 standards were inspected on this occasion of which 4 had shortfalls. Two of the residents were at home for part of the day and were spoken with informally. The house leader was on duty during the inspection, and the manager arrived later in the morning. In addition to this, records, files and policies and procedures were also inspected. The home has recently undergone a change of manager, with the new manager only being in post for a short time. The inspector would like to thank the manager, the house leader and residents for their co-operation and hospitality during the inspection. What the service does well: What has improved since the last inspection? Since the previous inspection the home has succeeded in obtaining relevant paperwork on which to form a view regarding the proposed admission of a 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 6 resident to the home. Confidential documentation is now stored securely, out of sight. Residents have ‘health action plans’, which are in the process of being completed. Policies required at the previous inspection have now been implemented. Staff have been trained in the recommended areas of assessment and care planning, working with challenging behaviour and communication techniques. A risk assessment for Legionella, and required actions has been completed. 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. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 The home offers a comprehensive introduction process to prospective residents to ensure that it is suitable for their needs. EVIDENCE: The home has not had any new residents admitted since the last inspection, therefore standards one to three are deemed to be not applicable on this occasion. Standard five was not inspected on this occasion. One resident moved into the home in November 2004. Evidence was available within her support plan to confirm that a number of trial visits were undertaken that included meals, sleepovers and general participation in household activities. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Residents needs are met by informed staff using comprehensive care planning documentation. Some risk assessments have not been reviewed or updated to safely ensure that staff have the current information to meet the resident’s needs. EVIDENCE: All residents have a support plan in place. The house leader stated that the format had been recently implemented recently by the manager. The house leader also stated that the staff had worked hard to get them completed with the residents, but acknowledged that further work was planned. In the files looked at Community Care Assessments and Care Plans were available, and had been used to form the basis of the organisations daily living and support assessments. Risk assessments specific to the needs of each resident were in place, and covered areas such as using the cooker, bathing and staying alone in the house. These were found to be signed and dated, however there was no date for review included in those looked at. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Residents are supported and encouraged to participate in age, peer and culturally appropriate activities. The importance of family links and contacts to the residents is actively promoted by the staff. EVIDENCE: All of the residents attend daytime activities for all or part of the week. One resident spoken with told the inspector about his love of horses, and how he works on a farm for three days each week, looking after the horses, which he said he enjoyed very much. As well as this he said that he attends a day centre for two days a week and a pottery class for one evening a week. Evidence was available within residents support plans to demonstrate that courses at a local college are also undertaken as well as attendance at day centres. Family links and contact are deemed to be important in the home, and evidence was available to confirm that residents are supported to maintain contact with their families if they so wish. One resident stated that he visits his family on a weekly basis. In a support plan examined, it was recorded that another resident visits their parents on a monthly basis. Observations made during the inspection demonstrated that the residents have good relationships with each other, and get on well within the setting of group living. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents’ personal care needs are identified and met. Residents’ healthcare needs are identified and monitored with routine and specialist appointments being arranged as necessary. Medication is generally managed safely. EVIDENCE: Residents support plans provided evidence of information about how best to provide individualised care and support in the form of care plans. These were dated and signed and covered areas such as bathing, and personal care. One plan looked at detailed the levels of self-care undertaken by the resident. All of the care plans had been completed within the last six months, and therefore did not yet need formal review, however there were no future review dates recorded. Information concerning healthcare was available, with records of appointments for routine checks such as dental, chiropody and optical being in place to confirm that they are offered at the recommended intervals. Evidence to confirm that specialist healthcare input was also received by professional services such as psychology and the Community Learning Disability Nurses was available. None of the residents currently administer their own medication. An organisational policy is in place that includes a section on the administration of homely remedies. Medication is supplied to the home by Boots in a Multi 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 12 dispensing system (MDS), and is accompanied by medication administration record sheets (MARS). Examination of a sample of administration records and MDS packs provided no cause for concern during the inspection. Medication is stored in a locked drawer in a desk within the second lounge / office. During the inspection a number of out of date homely remedies were found which the house leader dealt with at the time. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: None of the standards in this section were inspected on this occasion. Standards 22 and 23 will be inspected at the next inspection of this home later in the 2005/06 inspection year. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 28 The home is comfortable and domestic in style, with easy access to the local town centre. Considerable shared space is available to residents in addition to their individual bedrooms. EVIDENCE: 30 Vicarage Road is a large three-storey town house in a residential area close to the town centre of Rugby. The ground floor consists of two lounges, one of which doubles as an office, and a large dining/ kitchen area. There are two upper floors, each with a bathroom. The six single bedrooms and one sleep in room for staff are divided between the first and second floors of the house. There is a courtyard at the rear and a range of outhouses. The registered manager is not based at the home, therefore no designated office space for her is available. One resident showed the inspector his bedroom during the inspection. He was observed to get his key out of his bag and unlock the door. The room was clean and tidy with no unpleasant odour apparent. The furniture was of a good quality, and the resident said that he had recently had a new bed. There was plenty of personalisation with pictures, ornaments and books. It was noted that the curtains needed rehanging, and the room would benefit from redecoration, as in some places the walls were looking worn and shabby. The furniture throughout the communal areas of the home was of a good 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 15 quality, with the main lounge especially, being very nicely decorated and furnished. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35 A committed, motivated staff team supports residents. Adequate training ensures that the majority of staff have the knowledge to safely support the residents within the community based setting. EVIDENCE: The home employs three staff on a permanent basis plus the registered manager who is also responsible for a second larger service within the organisation. At the time of the inspection a vacancy for a fourth permanent member of staff had been filled, and the home was awaiting confirmation of a start date. The home is staffed by one or two staff members throughout the day, as necessitated by the residents and their planned activities. Over night one member of staff sleeps in to provide support to the residents should it be needed. The manager stated that she spends approximately two hours in the service each week, but provides support from her base in another of the organisations homes as required. The house leader stated that her role has recently been clarified within the team as being responsible for the day to day running of the home, with support from the registered manager. A monthly audit is undertaken by the registered manager to ensure that the house leader is carrying out her role to an acceptable standard. Information regarding training was supplied by the registered manager subsequent to the inspection. This confirmed that all staff have been registered on the Learning Disability Awards Framework. Two staff have completed NVQ II, and the house 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 17 leader has commenced NVQ III. Two members of staff have undertaken all of the mandatory training within the last two years, with a third requiring training in the areas of fire safety, medication administration, moving and handling and protection from abuse. More specialist training has also been provided in the areas of challenging behaviour, communication and makaton, and dementia. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 The home has a new manager in post, making it difficult to determine the impact of her management style and ethos at this inspection. The health and safety of residents and staff is maintained. EVIDENCE: The registered manager has been in post for a relatively short period of time, therefore it was not possible to determine the impact of her management style upon the home at this inspection. The house leader stated that a number of areas have been improved upon since the manager commenced work, not least of which is the format of the residents support plans. As recorded previously, the registered manager said that she spends an average of approximately two hours per week in the home. In order to ensure that the residents and staff benefit from her leadership and management ethos this is not deemed to be enough. Records to confirm that the necessary health and safety checks are carried out in accordance with legislation were in place. The organisation and a registered 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 19 plumber carried out a risk assessment for Legionella and other infections within the piped water supply in June 2005. This includes any action necessary to reduce the risks of possible infection from the water supply. Maintenance support is provided from a larger home within the organisation, which also incorporates the main offices of the organisation. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x 3 x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score 3 x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 30 Vicarage Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x 2 2 x x 3 x DS0000004286.V251281.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard 9 20 Regulation 13(4)(c) 13(2)(4) (c ) 13(2)(4) (c ) 18(1) (c )(i) Requirement All risk assessments must have review dates included within them. Homely remedies purchased for the residents must be checked regularly to ensure that they are still within date. Creams, lotions and bottles must be clearly dated when opened, and disposed of in line with pharmaceutical guidelines. Evidence must be provided as part of the action plan for this report to confirm that all staff have been trained in the administration of medication, before undertaking this task with residents. All staff must be trained in the mandatory areas of fire safety, moving and handling and protection from abuse. The registered person must ensure that the registered manager spends more time providing an operational presence in the home. (Carried forwards from previous inspection as timescale of 01/07/05 not met) DS0000004286.V251281.R01.S.doc Timescale for action 30/11/05 31/12/05 30/11/05 3 20 4 20, 35 30/11/05 5 35 18(1) (c )(i) 8 31/12/05 6 38 30/11/05 30 Vicarage Road Version 5.0 Page 22 7 39 24 The registered person must ensure that a system for reviewing the quality of care in the home is established and maintained and a report of any review be sent to the commission, and made available to residents. (Not inspected on this occasion.) 31/01/06 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 Refer to Standard 20 25 Good Practice Recommendations It is recommended that residents medication that is not supplied within blister packs be stored within separate containers in the locked facility. The bedroom inspected would benefit from redecoration. 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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 30 Vicarage Road DS0000004286.V251281.R01.S.doc Version 5.0 Page 24 - 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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