Inspection on 08/07/05 for Lady Of The Vale

This inspection was carried out on 8th July 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 21/12/05

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 8 July 2005 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 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 F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 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 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 CRH Care home N Care home with nursing 38 38 Category(ies) of OP Old age registration, with number of places Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 19 October 2004 Brief Description of the Service: Lady of The Vale Nursing Home is a large detached care home providing nursing care and accomodation for up to 38 older people. The home is a large detached house consisting of 34 single bedrooms and 2 double bedrooms over three floors. There are number of communal areas and a chapel within the home where attendance at mass or Holy Communion can be received. The home is surrounded by mature gardens and residents have access to these. Ample car parking is provided at the front and side of the building. The home is under the ownership of the Sisters of St Joseph of the Apparition. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection which took place over the course of 6 hours on Friday 8th July 2005. During the course of the inspection time was spent talking to numerous residents, relatives and members of staff to find out their views of the home. At this inspection a limited number of standards only were inspected. This report should be read together with the previous and any future reports to gain a full picture of how the service is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements have been made with this report with a number of the requirements having been brought forward from those not met from the Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 6 last inspection. Some development has been made with these however further input is required. The staff require further training and development in the writing of care plans and the writing of risk assessments. The recording practices for medication received into the home required action. Staff observed were attentive to the residents’ needs. There was no evidence that formal staff supervision was being carried out however this was apparently done informally as the manager worked with the staff. Staff required training in how to deal with allegations of abuse. The residents must be protected by thoroughly vetting all potential employees, holding accurate records prior to allowing them to work at the home. Action is required to provide a fire risk assessment as a matter of urgency and for staff to be aware of this. 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 F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 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 standard(s) 3, 5 and 6 New residents are admitted only after a full needs assessment has been undertaken. Potential residents, relatives and /or friends are able to visit the home before making the decision to stay. EVIDENCE: Pre admission assessments had been carried out on all admissions to the home prior to them residing at Lady of The Vale. Copies of these were not held on all residents files examined however there was evidence that the staff had transferred this information for a number of residents onto the home’s own pre admission format. It is strongly recommended that copies of referral information from social services is available within the care planning documentation. Where possible the residents, relatives or representative were encouraged to visit the home prior to making a decision to move into Lady of The Vale Nursing Home. The home did not offer intermediate care services. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. Each resident had an individual plan of care, however improvements are required in some areas of the documentation to ensure the residents’ healthcare needs are fully met and residents are not at risk. Some aspects of medication recording was putting residents at risk. EVIDENCE: A sample of care plans were examined and although there was some improvements noted since the last inspection there were the following concerns: 1. 2. There was a lack of updated nutritional risk assessments. Manual handling risk assessments had not been reviewed for a number of months. One resident had fallen in June 05 and the accident resulted in a fractured wrist. The risk assessment had not been updated to reflect the changes required. The pressure sore risk assessment for more than one resident had not been updated for a number of months and stated ‘nurse on pressure relieving mattress’ rather than stating the specific mattress and or cushion. It was of serious concern that one residents pressure sore risk assessment showed them to be ‘very high risk’, but examination of the F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 10 3. Lady of The Vale 4. 5. mattress the resident was being nursed on showed this to be an overlay rather than an appropriate air mattress. The diary showed that staff had requested a ‘Visco elastic memory foam’ mattress on the 28.06.05 and the 5.07.05. The social activity plans had not been completed in some of the care plans examined. Daily statements regularly reported; ‘comfortable morning’, ‘good night’ and these were not linked to the nursing problems identified. A discussion with the deputy manager highlighted that staff had received training in the use of the standex care planning system since the last inspection. A further requirement was made for staff to accurately complete the care planning documentation in order to fully reflect the assessed needs, planned care and outcomes for residents. The home must ensure that evidence is provided that care staff maintain nail care and oral hygiene of the residents and encourage residents to self care when possible. Care plans included evidence of visits by other professionals, for example, tissue viability, opticians and General Practitioners. It was pleasing to see that the psychological and physical assessments for a resident admitted in April 2005 were detailed and that a detailed wound assessment care plan was available for another resident. Two requirements made at the previous inspection concerning medication practice and the provision of an appropriate Controlled Drugs storage cabinet had not been fully actioned. A follow up visit to the pharmacy inspection carried out in November 2004 by the pharmacy inspector was made on the 13 December 2004 where a number of concerns were raised which could put residents at risk and a further 5 requirements were made. These concerns were as follows: 1. 2. 3. 4. 5. 6 7. The medication policy and procedure was out of date and required amending. Medication was not signed for when it was received into the home. There was no formal method for the disposal of medication. The Controlled Drugs Storage cabinet remains inadequate. This has been the subject of previous requirements the timescale of which lapsed on the 4.2.05. Appropriate action must be taken if the fridge temperature for medication storage is outside the range of 2-8 degrees C. .Issues were raised concerning the supply of spare labels by the pharmacy for nurses to affix to the medication administration records. Some errors noted in the record keeping of medication highlighted the need for registered nurses to administer all medication in accordance with the directions of the prescriber. F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 11 Lady of The Vale 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 standard(s) 13, 14 and 15 Social activities were provided on a group basis and on a 1:1 basis for some residents. The residents were provided with a varied, appealing diet however nutritional needs were not assessed in full for all residents. EVIDENCE: On the day of the inspection residents spoke about a trip to Chester Zoo they had been on the week before and expressed they had thoroughly enjoyed this outing. The physiotherapist was assisting a group of 10 residents with exercises during the inspection. Staff were observed encouraging residents to talk, sing and show an interest in what was on the television by stimulating conversation. Staff knew the residents well as individuals and their likes and dislikes. The recording of residents preferences for social activities was limited in some of the care plans examined. The menu examined was on a 4 weekly rota system. Menu selection was made on the previous day. Residents and relatives generally spoke highly of the food provided, however two of the residents stated their desert was cold as it was served at the same time as their main course. Residents had a choice as to whether to eat in the dining room, lounge or their own bedroom. Staff were observed to be pleasant, sensitive and courteous in Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 12 interacting and providing additional support at the lunch time meal as required. Families and friends were encouraged to visit the home and spend time with their relatives. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 The home had a complaints procedure which residents and relatives were aware of. The homes policies and procedures required updating to ensure residents are protected from abuse. EVIDENCE: The complaints procedure was on display. Residents and relatives spoken to were aware of how to make a complaint. The Commission for Social Care Inspection has received 2 complaints which were not upheld since the last inspection. The policies and procedures for the Protection of Vulnerable Adults from abuse required reviewing and updating. Staff spoken to were not familiar with the homes procedure for dealing with an allegation of abuse. A requirement made at the last inspection for staff to receive training in Adult protection had not been addressed. The timescale for this requirement was 20.01.05. This requirement has been reiterated in this report. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 21, 22, 23, 24, 25 and 26 The home was fit for its stated purpose and provided clean and comfortable surroundings. Some improvements had been made internally to the décor. EVIDENCE: There was evidence that the home had undergone some redecoration and re carpeting since the last inspection. This included the upstairs lounge area and the dining room on the ground floor and the corridors having been repainted. In response to a requirement made at the last inspection for residents to be provided with locks to their private accommodation, the inspector was advised this has been estimated for. The requirement has been reiterated although some risk assessments have been completed for resident’s whose capabilities would not suit a lock. A lock and key must be provided suited to the resident’s capabilities and accessible to staff in emergencies. Residents spoken to liked their own bedrooms and felt happy with the furnishings provided. A tour of the home highlighted that the bath/shower Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 15 room on the first floor required upgrading. Staff were taking residents to the ground floor to use the shower on this floor at the time of the inspection. A requirement made at the last inspection regarding the installation of a sluicing disinfector has been reiterated It was pleasing to see that the majority of the beds were adjustable height beds and assessments were carried out to ensure these were in line with needs assessments. Externally, the gardens and grounds are well maintained. A staff member was seen sitting with a resident in the grounds having a chat in the afternoon. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the residents. The home’s recruitment procedures must be reviewed so as to protect and safeguard the resident’s accommodated. EVIDENCE: At the time of the inspection the home accommodated 36 residents requiring nursing care. One resident was in hospital. The numbers and skill mix of the staff appeared to be sufficient to meet the needs of the numbers of residents accommodated. The staffing rota included the capacity in which staff worked and the shift allocated. It is strongly recommended that any agency staff allocated shifts are named on the rota. It is pleasing to see that by August a further two staff members will have completed NVQ 3. It is a condition of registration for the home that night staffing levels include a care staff member with NVQ Level 3. One resident stated,“ the staff are generally very good they take time out and come and chat to me. The meals are tasty and there are always alternatives available”. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 17 A sample of staff files were examined during the inspection. These files did not include all the information listed in Schedule 2 of the Care Homes Regulations 2001. The uptake of Criminal Records Bureau (CRB) disclosures was not available for all staff. A full audit of all staff employed must be made and appropriate CRB POVA first checks must be carried out. There was no evidence that a number of staff had undertaken a full induction training programme although a format was available. It was difficult to establish from the records when the staff had received mandatory training. It is recommended that all staff have an individual training and development plan to evidence the training they have received. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 and 38 Some areas of practice did not always promote the health, safety and welfare of the residents however residents’ interests were promoted. A system for the formal supervision of staff was not in place. EVIDENCE: An updated fire risk assessment was not available at the time of the inspection. The deputy manager said this was being worked on currently. A requirement has been made for this risk assessment to be completed. Evidence of fire safety training was available for 31 staff members in March and April 2005. According to the records the last fire drill appeared to have been carried out in March 2004. It was not clear therefore whether or not all staff have attended a fire drill in the last 12 months as this record did not include the time of this drill. The ethos of the home was generally felt to be in the best interest of the residents. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 19 Evidence of weekly fire safety checks was available however these should be carried out by a competent staff member when the maintenance man is on annual leave. A requirement made at the previous inspection which expired on the 20.01.05 was to ensure that all care staff receive 6 formal supervision sessions per year. This process appeared to be carried out on an informal basis however appropriate records must be maintained to demonstrate this is being actioned. This requirement has been reiterated. Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 2 3 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x x 2 x 2 Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? 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 Timescale for action 25/11/05 2. OP9 13(2) 3. OP9 13(2) 1.All residents must have an individual plan of care that sets out in detail the action which needs to be taken to ensure that all aspects of health,personal and care needs are met. 2.Care plans must be reviewed on a monthly basis to reflect any changes to care needs.. 3.Where possible the plan of care must be drawn up with the involvement of the resident and or their representative. The registered person must 14/11/05 make arrangements for the recording, safe keeping, safe administration, handling and disposal of medication. The previous timescale of 10.01.05.had not been met. The 5 requirements raised by the pharmacy inspector in December 2004 must be met. The registered person must 30/11/05 supply a controlled drugs cupboard which is compliant with current regulations. Misuse of Drugs (safe custody) Regulations 1971. The previous timescale of 4.02.05 had not been met. Version 1.30 Lady of The Vale F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Page 22 4. OP18 13 5. OP24 12(4)(a) 6. 7. OP26 OP36 13(3) 18(2) 8. 9. OP21 OP29 23(2)(j) 19(1)(a) 10. OP38 23(4)(a) 1.The homes policies and procedures for responding to suspicion or evidence of abuse or neglect must be reviewed to reflect the Department of Healths No Secrets guidance. The previous timescale of the 20.01.05 had not been met. 2.All staff must receive training in the action to be taken in the event of an allegation of abuse. Residents must have a key to their bedroom unless their risk assessment suggests otherwise. The previous timescale of 18.02.05 had not been met. A sluicing disinfector must be provided. Care staff must receive 6 formal supervision sessions per year. The previous timescale of 20.01.05 had not been met. The bath/shower room on the first floor requires upgrading. The recruitment procedures for the home must include the taking up POVA 1st and CRB checks before staff are deployed. A fire risk assessment must be completed and weekly fire safety checks carried out. 15/12/05 30/01/06 30/01/05 30/10/05 20/02/06 14/10/05 14/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP31 OP1 OP15 Good Practice Recommendations The registered manager should ensure she will achieve NVQ L4 in management , or its equivalent by 2005. Copies of referral /assessment information should be available within the care planning documentation. To review mealtime procedures and serve deserts after residents have eaten their main course. F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 Page 23 Lady of The Vale Commission for Social Care Inspection 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 F05 F55 s6715 lady of the vale v229789 130605 stage 4.doc Version 1.30 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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