Inspection on 08/09/06 for Lady Of The Vale

This inspection was carried out on 8th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Lady Of The Vale 03/09/08

Lady Of The Vale 21/12/05

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 8th September 2006 09:30 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.V298158.R02.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. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 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.V298158.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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 night time 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. 21st December 2005 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 daily 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.V298158.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and took place on Friday 8th September 2006. All the core National Minimum Standards (NMS) were reviewed during this inspection. Information was gathered as part of the inspection process, which included a questionnaire completed by the manager, which gave information about the residents, the staff and the building. Information held by the Commission, for example, notifications and significant incidents were also reviewed. Time was spent talking to the residents, visiting relatives, the manager and the staff team about day-to-day life in the home and to establish what the home was like for the residents living there. A tour of the premises was undertaken and examination of documents and care files for the individual residents. Two of the ten resident/relatives questionnaires were returned to the Commission. What the service does well: What has improved since the last inspection? Some improvements had been made in the systems and procedures for the nursing staff dealing with medication however recording practices require further attention. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 6 Some staff training had been carried out since the last inspection including fire awareness, palliative care and care planning, blood glucose monitoring and drug administration. The manager encouraged staff to receive training. Following the last inspection and the requirement in relation to upgrading the satellite kitchens it was pleasing to see the work had been completed on the ground floor kitchen and the first floor was due to start the week after this inspection. 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.V298158.R02.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 Lady Of The Vale DS0000006715.V298158.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this area outcome is good. This judgement has been made using evidence made available and following a visit to the home. Procedures are available to ensure the needs of prospective residents are assessed before the offer of a place is made. The documentation needs reviewing for privately funded residents. EVIDENCE: Since the last inspection the Statement of Purpose and Service User Guide had been reviewed. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment prior to admission. The documentation for privately funded residents required developing further to include all activities of daily living. There was evidence that the admission process included involvement of the prospective resident, his/her representatives and any relevant professionals. The home does not provide an intermediate care service. Lady Of The Vale DS0000006715.V298158.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to this service. Each resident had an individual plan of care, however, shortfalls in the documentation had the potential to lead to resident’s health, social and personal care needs not being fully met. Shortfalls in the recording of medication had the potential to put residents at risk. EVIDENCE: A sample of care plans was examined. Some serious concerns were noted during a review of the care plans. The care plans did not always detail the specific action required of the staff for them to meet the resident’s needs. The individual care plan for a resident who had recently been discharged from hospital had not been updated and did not specify the changed healthcare needs for this resident. Care plans written in relation to wound care and its management were not well detailed, poorly recorded and not well evaluated. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 10 There was evidence that professional advice had been sought from the tissue viability nurse however it was of serious concern that the instructions given had not been acted upon immediately following the advice or transferred into the individual care plan. There was evidence of some outdated practice for example, use of a sheepskin on top of a pressure-relieving cushion. This highlights a training need for the staff in relation to current pressure care management and use of equipment. Risk assessments were present however these did not always contain sufficient detail, for example they did not specify the type of hoist required for the individual. The tissue viability nurse had requested a review of a resident’s analgesia. There was no evidence to suggest this had been carried out and the medication administration record for this individual showed that the mild analgesic had not been administered on a regular basis. Medication records were examined during this inspection and there were a number of gaps in the recordings of medication. Use of correction fluid was noted on the medication administration record, which is not good practice on a legal document. From observations made during the inspection and discussions with members of staff and residents it appeared that the nurses and care staff treated the residents with respect and dignity. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 11 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, 13, 14 and 15 Quality in this area outcome is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle in the home generally matches their expectations and preferences. Some activities/excursions were provided and residents were able to maintain contact with family and friends. Residents were able to exercise choice over their lives and the residents enjoyed the meals they chose. EVIDENCE: The home supports the residents to meet their individual lifestyles. Mass is said on a daily basis and a number of residents stated this was an important part of their daily routine. Recent activities included a visit by an aromatherapist, singing classes, theatre visits and a trip was planned for a “Harry Ramsden” cruise. On the day of the inspection the physiotherapist held an exercise class to promote activity. It was pleasing to see following a requirement made at the last inspection for the care plan to contain a record of the activities a resident has participated in that an activities record had been developed, however this was not always filled in. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 12 As raised at the last inspection it was of concern that there is a general lack of stimulation on a daily basis and the televisions were on for lengthy periods of time. A discussion with the manager highlighted the need for more individual/group activities and some training in meeting the needs of residents with a dementia type illness. One resident commented in the questionnaire,”It would be a good idea to have a quiz or bingo type activity a couple of times a week, painting or drawing might be another option.” The home had an open visiting policy and visitors could be received in the resident’s own room or any of the communal areas of the home. Residents and staff spoken to confirmed this. Following discussions with residents and staff it was clear that residents are able to exercise some choice and control over their lives. Evidence was seen that residents are able to bring personal possessions into the home. One resident stated the staff were “fabulous and very attentive to me”; another resident said, “The staff are very kind and considerate”. Menus had been developed in line with residents’ likes and dislikes and offered a varied, wholesome and nutritious diet. Residents’ comments were positive in relation to the meals. A choice of meals was available at each mealtime and the chef confirmed that if residents did not want the choices on the menu he would prepare an alternative. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for managing complaints and the residents and their relatives are confident that the home will deal with their complaints appropriately. Some shortfalls in the Adult Protection policy and training in Adult Protection may put residents at risk. EVIDENCE: The complaints procedure was available on display and is included in the Service User Guide to the home. The home had not received any complaints since the last inspection. There was evidence that the home had reviewed the Adult Protection procedure however this still did not clearly outline the course of action the staff must take in the event of an allegation of abuse. The policy on Whistle Blowing had been developed. Some staff had undertaken Adult Protection training since the last inspection however this had not been extended to all staff working in the home and a requirement was made for this to be addressed. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 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 the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are comfortable and homely and the home is well maintained both internally and externally. EVIDENCE: The home provides a homely environment with well-maintained grounds. The resident’s bedrooms were seen to be homely, comfortable and personalised. Two new baths have been installed since the last inspection and plans to lease a sluicing disinfector have been put in place. There was evidence of a programme of redecoration. A tour of the home showed that the hall carpet was in need of deep cleaning however the manager stated this was planned for. The garden areas are well maintained and the staff and residents confirmed they spent time in these areas. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 15 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): 27, 28, 29 and 30 Quality in this area outcome is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared in general sufficient to meet the residents’ assessed needs. Some shortfalls in the home’s recruitment and selection procedures may lead to residents not being fully protected. EVIDENCE: On the day of the inspection the numbers of staff on duty and the skill mix appeared appropriate to meet the needs of the residents accommodated. The home employs 25 carers, 15 members of care staff have successfully achieved NVQ level 2. Staff spoken too said they enjoyed training and there was evidence of individual training and development plans. A sample of staff files was examined. A review of the pre inspection questionnaire highlighted that Criminal Records Bureau disclosures had not been carried out for ancillary staff employed. A requirement was made for this to be addressed as a matter of urgency. A discussion with the manager highlighted the need to introduce a system to flag up when individual staff members were due mandatory training. Since the last inspection the staff had commenced training in Palliative Care. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 16 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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the systems in place to monitor the service based on people’s views. The health, safety and welfare of the residents’ was promoted. EVIDENCE: The manager demonstrated that she knew the residents well. The manager has completed the Registered Managers Award and plans to commence a Diploma in Management with the Open University. A questionnaire was available to seek the views of residents/relatives however this had not been sent out in the last 12 months. It is also recommended that a quality audit tool be also sent out to visiting professionals to the home. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 17 Policies and procedures were in place to protect the personal allowances of the residents accommodated. Fire safety checks were being carried out on a regular basis. Staff had attended a fire drill on the 10/01/06. The manager in a pre-inspection questionnaire provided information. The information provided highlighted that the 5 yearly electrical check was due. Accident records were appropriately completed. The manager audited these on a monthly basis and reviewed the residents care plan/risk assessment following this. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 18 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 19 No 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 OP3 Regulation 14(1) Requirement The needs of a self-funding individual must be fully assessed covering all activities of daily living. The plans of care must fully identify the needs of the residents accommodated and must be reviewed when residents’ needs change. All staff must have training /guidance in the implementation of the Protection of Adults from abuse. Arrangements must be made for the recording, safekeeping and safe administration, handling and disposal of medication. Timescale for action 30/10/06 2. OP7 15(1) 30/10/06 3. OP18 13 06/11/06 5. OP9 13 29/09/06 6. OP18 13 Policies and procedures must be 30/10/06 developed for responding to suspicion or evidence of abuse or neglect. All staff employed in the home must have satisfactory Criminal Records Bureau Disclosure checks. DS0000006715.V298158.R02.S.doc 7 OP29 19 27/10/06 Lady Of The Vale Version 5.2 Page 20 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 OP12 Good Practice Recommendations The home should ensure residents are consulted about a programme of activities. A record should be made in the individual care plan to show their participation. Lady Of The Vale DS0000006715.V298158.R02.S.doc Version 5.2 Page 21 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. 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