Inspection on 14/12/05 for Old Vicarage, The

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Old Vicarage, The 13/11/07

Old Vicarage, The 25/10/06

Old Vicarage, The 07/07/05

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage, The 26 Cottage Road Wooler Northumberland NE71 6AD Lead Inspector Anne Urwin Brown Unannounced Inspection 14th December 2005 08:30 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 DS0000064203.V258406.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. DS0000064203.V258406.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Vicarage, The Address 26 Cottage Road Wooler Northumberland NE71 6AD 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) 01668 281662 A & P Ltd Mrs Janet Cresswell Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places DS0000064203.V258406.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: The old Vicarage is a stone built detached house on the outskirts of Wooler. This former vicarage has been extended and converted to provide residential accommodation for up to seventeen older people. Day care is also provided for up to five older people. The public rooms, which are comfortable and spacious are on the ground floor. There is a shaft lift fitted for access to the first floor. The home stands in its own grounds, which are accessible and well maintained. Car parking is available to the front and rear of the house. Public transport is available in the centre of Wooler a short walk from the home. The home has an estate care that is used to transport residents. DS0000064203.V258406.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 over half a day. It included discussion with the deputy manager, six residents, three staff, inspection of four residents’ records, other associated records and a tour of the building. What the service does well: What has improved since the last inspection? Most residents now have a written contract/statement of terms and conditions with the home; these have been issued at annual reviews. Attention has been given to providing more recreational activities since the last inspection. The manager is working to review all policies and procedures. A new care planning system has been introduced that provides comprehensive information about residents’ needs. Work is going on to complete all residents’ care plans in the new format. A staff training plan has been started, but needs more work to identify all training needs. A new format for recording complaints has been introduced and is an improvement on the previous system. DS0000064203.V258406.R01.S.doc Version 5.0 Page 6 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. DS0000064203.V258406.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 DS0000064203.V258406.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): 4 Residents and their representatives know that the home will meet their needs. EVIDENCE: Evidence was available from records and discussion with staff that specialist support is provided to meet identified residents’ needs. Examples included care for people with dementia and physical disabilities. Staff are experienced in the care of older people and have the skills to deliver the care that is offered at the Old Vicarage. DS0000064203.V258406.R01.S.doc Version 5.0 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, 10 Each resident’s health, personal and social care needs are set out in an individual care plan. Residents’ health care needs are met. Residents are responsible where appropriate for their own medication. The home’s policies and procedures for dealing with medicines protect residents. Residents feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: The care planning system has been reviewed since the last inspection and work is going on to complete all care plans in the new format. Each resident’s plan is being reviewed and the new format introduced. Each person’s needs, goals and information about how the goals and needs are met are available in a simple format. This is a significant improvement on the last care plans, which did not contain so much detail. The deputy manager confirmed that residents are involved in preparing care plans as they supply a lot of the information available. Risk assessments are in place for falls, moving and handling and pressure areas. There is a system for reviewing the care plans to reflect residents’ changing needs. Evidence was available in individual records that residents health needs are identified and met. Records show there are regular reviews of the incidence of DS0000064203.V258406.R01.S.doc Version 5.0 Page 10 pressure areas and risks are assessed individually. Most residents are registered with the local doctors in Wooler. Policies and procedures are in place for ordering, administering and disposal of medicines. Records are kept of any assessments undertaken if residents want to administer their own medicines. Records are kept of the administration, ordering and disposal of medicines and those seen during the inspection were in good order. Arrangements for the storage of medicines are satisfactory. Written guidance is in place relating to privacy and dignity. None of the residents shares a room. The need to respect privacy and dignity of residents is part of the staff induction training. During the inspection staff treated residents with respect and they showed a good understanding of the need to respect individuals’ privacy. Residents confirmed that the staff treat them respectfully and do respect their privacy. DS0000064203.V258406.R01.S.doc Version 5.0 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): 14 Residents are helped to exercise choice and control over their lives. EVIDENCE: Residents said they could make choices about their daily routines and activities. The deputy manager confirmed that it is the home’s policy to encourage residents to manage their own finances for as long as they are able. Residents confirmed that they were able to bring in personal possessions from their previous homes. Bedrooms show evidence of this. Residents confirmed that they could access their personal records if they wanted to. Residents are involved in preparing care plans and signing them when they are completed to their satisfaction. The deputy manager confirmed that residents can be assisted to access an advocate who will act in their best interests. DS0000064203.V258406.R01.S.doc Version 5.0 Page 12 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 Residents, their relatives and friends are satisfied that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Written guidance has recently been reviewed and provides appropriate information about handling with complaints. No complaints have been made since the last inspection. A new format for recording complaints has been introduced and this is an improvement on the previous system. Staff were aware of how to assist a resident to make a complaint. Residents said that they felt able to raise issues or make a complaint to any member of staff. DS0000064203.V258406.R01.S.doc Version 5.0 Page 13 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 Residents live in a safe, well-maintained environment. EVIDENCE: A maintenance plan is in place and it is regularly checked by senior staff. Evidence of refurbishment was available, rooms are regularly re-decorated and re-carpeted. All work recommended by the Fire Officer and Environmental Health department has been completed. The grounds are well maintained, attractive and are easily accessible for residents. Residents said they are very satisfied with the environment and very much enjoy spending time in the garden. DS0000064203.V258406.R01.S.doc Version 5.0 Page 14 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 There are sufficient staff with appropriate skills to meet the needs of the current residents. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The staff rota showed that appropriate numbers of staff are available during the day and night. Three staff and the deputy manager were on duty at the time of this inspection. There is a senior member of staff on duty at all times. Staff said that there were enough staff to cover the rota. Existing staff work extra hours to cover sickness and annual leave. One waking care assistant is on duty at night and one person sleeps in the home on call. Residents said that they felt there were sufficient staff to meet their needs and that staff always made time to spend with them. No staff under eighteen years are employed. Sufficient domestic staff are employed. More than half the care staff have completed training in care. The home’s management is committed to providing appropriate training and is to be commended for this. Appropriate recruitment policies and procedures are in place. Records show that these are followed when appointing staff. Staff records confirm that two written references and a clear Criminal Records Bureau check are obtained prior to new staff starting work. Staff receive a statement of terms and conditions of employment. Staff have access to the code of conduct and practice set by the General Social Care Council. DS0000064203.V258406.R01.S.doc Version 5.0 Page 15 DS0000064203.V258406.R01.S.doc Version 5.0 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): 32, 36, 37, 38 Residents benefit from the ethos, leadership and management approach of the home. All staff are not yet receiving supervision at appropriate intervals. Residents’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager provides clear direction and leadership that is understood by residents and staff and that relates to the statement of purpose of the home. Residents and staff said that they are satisfied that the manager is open to listening to their views about the running of the home. The changes that have taken place in the home since the manager’s appointment have been undertaken after discussion with staff and residents. Staff said they feel able to put forward their views at regular meetings and at other times to the manager. DS0000064203.V258406.R01.S.doc Version 5.0 Page 17 Records show that senior staff are now receiving supervision. While care staff said during the inspection that they feel well supported a programme of formal supervision for care staff has not yet been introduced. This matter needs to be given priority. Records are kept in an appropriate form and kept securely. Records seen during this inspection were up to date and in good order. Residents are encouraged to access their records as part of the care planning process. Care plan records signed by residents were seen during this inspection. A new training programme for moving and handling, first aid, food hygiene and infection control is being implemented. Some staff need updating training. Appropriate induction training is provided for new staff. Written guidance is in place for Health and Safety and Infection Control. Control of Substances Hazardous to Health is also the subject of written policies and procedures. Fire records are maintained in good order and show evidence of regular testing and servicing. DS0000064203.V258406.R01.S.doc Version 5.0 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 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X X 2 3 2 DS0000064203.V258406.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP2 Regulation 5 Requirement Each resident must be issued with a written contract or statement of terms and conditions. This requirement is outstanding from the previous two reports, but is being addressed as part of the annual review process. 2 3 OP36 OP38 18 18 Arrangements must be in place for the provision of regular staff supervision. Arrangements must be made for staff to receive regular updating training in safe working practices. 31/03/06 31/03/06 Timescale for action 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000064203.V258406.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000064203.V258406.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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