Inspection on 21/12/05 for Lady Of The Vale

This inspection was carried out on 21st December 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

Lady Of The Vale 03/09/08

Lady Of The Vale 08/09/06

Lady Of The Vale 08/07/05

Lady Of The Vale 19/10/04

Lady Of The Vale 18/05/04

Lady Of The Vale 23/09/03

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Lady Of The Vale Grange Road Bowdon Altrincham Cheshire WA14 3HA Lead Inspector Elizabeth Holt Unannounced Inspection 21st December 2005 11:00 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 Lady Of The Vale DS0000006715.V270456.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 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. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lady Of The Vale Address Grange Road Bowdon Altrincham Cheshire WA14 3HA 0161 928 2567 0161 928 2119 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) Sisters of St Joseph Joanna Catherine Pimlett Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users requiring nursing care shall be 36. In addition a maximum of 2 service users who require personal care only may be accommodated. The home will comply with the minimum staffing levels as specified in the Notice of Proposal issued under Section 13 of the Care Standards Act 2000 on 15 December 2003. The service should, at all times, employ a suitably qualified and experienced manager who is registered with National Care Standards Commission. The nighttime staffing hours should include one nursing assistant who is qualified to NVQ level III. Only service users who actively wish to share a room can be accommodated in the double bedrooms. This agreement to share must be recorded in the service users` plans. 8th July 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Lady of the Vale is a large detached care home providing nursing care and accommodation for up to 38 older people. The home is a large detached house providing 34 single bedrooms and 2 double bedrooms over 3 floors. The home is owned by the Sisters of St Joseph of the Apparition. There are 4 lounge/dining areas for residents/relatives and a chapel where mass is said on a regular basis. The home is surrounded by mature, well-maintained gardens and residents can access these. Ample car parking is provided at the front and side of the building. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 21st December 2005 took place between the hours of 11.00 and 16.30. The inspection included a tour of the home. Residents spoken to were positive in their comments about the standards of care and the accommodation provided. Residents’ records and records in relation to medication, fire, health and safety and care were examined Key National Minimum Standards not assessed at the previous inspection were assessed; therefore in order to gain a full picture this report should be read with the previous report. What the service does well: What has improved since the last inspection? Since the last inspection, staff had received training in the writing of care plans. The registered nurse’s staff hours had been increased to provide extra time for staff to undertake the writing of care plans. A distance learning training course had been planned regarding risk assessments for this year and training had been planned for staff in Adult Protection. Although not all requirements made at the last inspection had been actioned, it was seen that steps had been taken to obtain quotations and make plans for these. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 6 Some refurbishment and redecoration had taken place since the last inspection. This had included the upstairs lounge and making a comfortable area in the hallway. There is an ongoing programme in place for redecoration. 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. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Information was available to enable residents and relatives to make an informed choice about the home, however this required updating. Residents’ needs were assessed before they were admitted to the home. EVIDENCE: The Statement of Purpose and the Service Users Guide were readily available, however the information required updating in relation to bed numbers and the Commission For Social Care Inspection. Residents were having their needs assessed before they moved into the home by a senior member of staff. Copies of the Multi-Disciplinary Assessment (MDA) were seen. Assessments from any other professionals involved in the care were used to assist in the decision making process as to whether the home could meet the prospective residents needs Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 9 The home did not provide Intermediate care. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Overall care plans were informing the staff of the residents’ needs, however some improvements were required to ensure their health and social care needs are fully met. Medication recording and storage was putting residents at risk. EVIDENCE: A selection of the care plans were examined and it was pleasing to see that progress had been made on the requirement that all aspects of health, personal and care needs are met. Plans were being reviewed on a monthly basis and there was some evidence of the involvement of the resident or relatives where possible. Staff were consistently not recording the date on which they were carrying out the initial assessments on the appropriate forms. The daily nursing reports in the care plans were not always showing the actual care given and did not reflect the care needs assessed as being required. Statements like “good day”, “comfortable day” and “good night” were used regularly. A requirement was made accordingly. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 11 Some risk assessments were included in the individual plan of care but they were limited and lacked detail. A requirement for these concerns was made. A discussion with the manager highlighted that staff have received more training in relation to completing the care planning documentation since the last inspection and the staffing levels for registered nurses had been increased two days a week to enable the staff to have the time to spend on the care plans. A distance-learning course had been planned for the New Year in relation to risk assessments. Equipment for the promotion of tissue viability and prevention/treatment of pressure sores was available. The staff at the home were seen to treat the residents with dignity and respect. Staff were seen talking to residents in a respectful and courteous manner. One of the requirements made at the previous two inspections concerning Controlled Drugs medication storage had still not been fully addressed. The pharmacy inspector has been asked to contact the home to discuss the appropriate storage cupboard for Controlled Drugs. A further requirement has been made to address this. Concerns following the pharmacy inspection of December 2004 were found to have been addressed except for the required amendments to the medication policy in relation to waste disposal. The following concerns were noted during this inspection: 1. Examination of the Medication Administration records (MARS) did show some gaps for medications not administered. 2. Photographs were not available for all residents accommodated which may put residents at risk. 3. There was no evidence to show that the temperature recording on the drugs fridge had been checked each day. Residents looked well cared for and were dressed in their own clothes. Staff spoken to respected the dignity of residents. One example included that they would change a residents clothing following lunch if they appeared unclean and this was seen to happen on the day. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Social activities are provided generally however on a daily, one to one basis variation in the daily home routine seems minimal. Residents were provided with a varied, wholesome balanced diet. EVIDENCE: One of the staff members who used to be a care worker has taken responsibility for arranging activities and visits from an external entertainer a few hours each week. A small play was being performed on the day of the inspection and carol singers had visited the home. Other recent activities had included hand massage, knitting and a visit from a war veteran who spent time talking to some of the residents. Whilst these are very positive activities and the staff appeared to know the residents well, there is a general lack of stimulation as the televisions in both lounges were on for lengthy periods of time and no activities were observed during the course of the inspection. A discussion with the manager highlighted that the residents often refused to participate in daily activities and therefore this made it more difficult. Participation in activities and residents personal preferences for activities must be recorded in their care plan. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 13 Menus were in place, which gave residents choice, and a number of residents spoken to said how good the food was. Nutritional risk assessments had been completed for the residents accommodated. The chef has now been in post for 3 years and communicated with the residents about their likes and dislikes. Food supplies were well stocked and included fresh fruit and vegetables. Fridge, freezer temperatures and core cooking temperatures were clearly recorded. Kitchen cleaning rotas were available and the kitchen was clean and tidy at the time of the inspection. Two relatives described the staff as being, “kind, calm and caring. They felt the home was well managed and the staff did very well to maintain a good standard of care for their relative and for others whom they observed too.” Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Lack of staff training and familiarity with how to implement the Protection of Vulnerable Adults from Abuse policy could put residents at risk. The home’s policies and procedures must be updated as a matter of urgency EVIDENCE: The complaints procedure was on display but is required to be updated to include the Commission for Social Care Inspection. The home did have a copy of Trafford’s multi-agency Protection of Vulnerable Adults, however the home’s procedure required developing as required at the last inspection. A policy on Whistle Blowing must also be developed and copies of these forwarded to the Commission. The manager stated that the training required at the last inspection regarding the implementation of the policy was scheduled to be provided by Trafford Care consortium in March and April 2006. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 25 The home is generally well maintained and comfortable. The kitchenettes required urgent attention to make them fit for purpose. EVIDENCE: Following a tour of the home it was pleasing to see that since the last inspection the programme of redecoration had continued and had included the upstairs lounge. An area under the fire door required revisiting to ensure its safety and homely look. The satellite kitchens are areas that now require urgent attention in particular: The kitchen units required replacing The broken window required replacing The rooms required a thorough cleaning Alternative storage places must be found for the mop and bucket. The residents’ bedrooms were homely, comfortable and personalised. Residents who chose to have a telephone had one for their own private use. It Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 16 was pleasing to see that the bathrooms on the ground and first floor had been upgraded since the last inspection. The requirement made at the last inspection for the installation of a sluicing disinfector had not been addressed however the manager said quotes had been looked into for this piece of equipment. The requirement has therefore been reiterated. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The home’s recruitment procedures must protect and safeguard the resident’s accommodated. EVIDENCE: At the time of the inspection the home accommodated 36 residents in receipt of nursing care and 2 in receipt of personal care only. It was pleasing to see that all the care staff had now completed NVQ level 2 or level 3. The night staffing levels included a care worker with NVQ level 3 each night. The staff spoken to clearly knew the likes and dislikes of the residents accommodated and were observed to have a good rapport with them. Staff training since the last inspection for a number of staff had included Safe Handling of Medication, Basic Food Hygiene, and First aid. Staff commented that they had found this valuable and they were keen to undertake training and development. The uptake of Criminal Records Bureau disclosures and POVA first checks prior to staff being deployed had been addressed following a requirement made at the last inspection. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 18 A sample of staff files was examined. There was an improvement since the last inspection however the manager should explore gaps in employment noted on an application form and record the reason for these at interview when identified. It is recommended that a record of interview notes are made and a format devised for this. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 and 38 The manager was fit to be in charge of the home and fully able to discharge her duties. A system for reviewing and updating policies and procedures was not in place EVIDENCE: Visitors and residents and staff generally made positive comments about the staff/management team. Policies and procedures were available however there was little evidence to show these had been updated in light of changing legislation and of good practice advice. These policies and procedures must be available to all staff when they have been reviewed and updated. A fire risk assessment had been completed since the last inspection and there was evidence of fire safety checks being carried out as required. A number of Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 20 recommendations had been made by the fire safety officer and a response to confirmation these have been carried out has been received from the home. Records showed that fire drills and fire instruction had been carried out. A staff-training booklet was available however it was difficult to establish that staff had undertaken this as the staff member retained the booklet. Staff must have an individual training plan and development plan to evidence the training they have undertaken. There was some evidence that staff had undertaken formal supervision however supervision must be available to all care staff on a regular basis. Supervision was carried out on an informal basis however records must show this is being carried out. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X 3 X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 2 Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 22 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 Standard OP7 Regulation 15(1) Requirement 1.The plans of care must include a detailed daily statement, which reflects the care delivered. Timescale for action 30/03/06 2 OP12 16 3 OP9 13 4 OP9 13 2. The plans of care must include detailed risk assessments to ensure unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The home must ensure residents 15/02/06 are consulted about a programme of activities and make sure this can be engaged in. A record within the individual care plans must be made to show their participation. 20/02/06 The registered person must supply a controlled drugs cupboard, which is compliant with current regulations. The misuse of Drugs (safe custody) regulations 1971. The previous timescales of 4.02.05 and 30.11.05 had not been met. Arrangements must be made for 10/02/06 the recording, safekeeping and safe administration, handling and disposal of medication. DS0000006715.V270456.R01.S.doc Version 5.0 Page 23 Lady Of The Vale 5 OP18 13 6 7 OP19 OP26 13 13 Policies and procedures must be 28/02/06 developed for responding to suspicion or evidence of abuse or neglect to reflect the Department of Health’s “No Secrets” guidance. Copies of these must be forwarded to the Commission for Social Care Inspection. The satellite kitchens must be 30/03/06 refurbished, cleaned and units replaced. A sluicing disinfector must be 30/03/06 installed. Plans to install this must be submitted to the CSCI. 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide must be accurate to reflect the accommodation provided. Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Lady Of The Vale DS0000006715.V270456.R01.S.doc Version 5.0 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. 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