Inspection on 19/12/05 for Old Vicarage, (The)

This inspection was carried out on 19th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Old Vicarage, (The) 03/06/08

Old Vicarage, (The) 18/07/07

Old Vicarage, (The) 07/04/06

Old Vicarage, (The) 26/10/04

Old Vicarage, (The) 17/05/04

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Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage, (The) Yeld Road Bakewell Derbyshire DE45 1FJ Lead Inspector Angela Kennedy Unannounced Inspection 19th December 2005 10:30 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 Old Vicarage, (The) DS0000052437.V270493.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. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Vicarage, (The) Address Yeld Road Bakewell Derbyshire DE45 1FJ 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) 01629 814659 01629 814330 The Westwick Group of Businesses Limited Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: The Old Vicarage is a well-established residential care home in the town of Bakewell. There is access to local facilities including shops, parks, library, cafes and public houses. The home is registered to admit up to 25 older people with personal care needs. The home is set within well maintained gardens and there is outside seating provision for the service users. Service user accommodation comprises 24 bedrooms on two floors, accessed by shaft lift of staircase. Nineteen of the bedrooms are equipped with en suite facilities. There are a variety of communal areas, including a conservatory at the rear of the building. Car parking space is provided at the front of the home. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was three hours. The lead inspector was supported by a second inspector- Denise Bate as part of an induction programme. A tour of the building was undertaken. Discussions took place with eight people who lived at the home, the acting manager and the proprietor. A number of records were examined during the visit, including care plans. Three people who lived at the home were case tracked (this is used to help determine how the home meets the needs of the individual person). An assessment was also made to address requirements made at the previous inspection. What the service does well: What has improved since the last inspection? Improvements environmentally include radiator guards that have been fitted to radiators throughout the home; this protects people living at the home from risk of heat injury. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 6 Staff have received some training updates in safe working practices, further dates have also been arranged in the new year, this provides reassurance that satisfactory efforts have and are being made to promote the health, safety and welfare of the people who live at the home 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. Old Vicarage, (The) DS0000052437.V270493.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 Old Vicarage, (The) DS0000052437.V270493.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, The written information about the service does not contain all the necessary information to enable the people living at the home and those considering living at the home to make an informed choice about where to live. EVIDENCE: The Statement of Purpose was examined, the written information was nicely presented in a suitable, easy to read format that contained some informative content, however it did not contain sufficient detail or explain how activities and services were provided and the level of involvement / choices that were available to the people living at the home. (This was a requirement from the last inspection) No service user guide was currently available for people living at the home, however the detail and content of Statement of Purpose in its current form is nearer to the definition of a service user guide, this was discussed with the acting manager and the proprietor. (This was a requirement from the last inspection) Old Vicarage, (The) DS0000052437.V270493.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): 7,9 The individual plan of care for people living at the home does not demonstrate consistency in its record keeping, which could lead to staff not having appropriate information when caring for people living at the home. People living at the home are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The care plan files examined as part of the case tracking process included some risk assessments. However, the daily records indicated that in a number of cases there were circumstances where risk assessments and more detailed care plans should have been carried out and these had not taken place. The home acknowledged that the good day-to-day communication between staff was not reflected in the standard of its care planning documentation. Records must have evidence of reviews within required timescales, and all entries and assessments must be fully completed, dated, signed and appropriately detailed. Further risk assessments need to be carried out for some of the people living at the home. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 10 It was noted that the review arrangements for privately funded people who live at the home were on informal lines, whereas people supported through social service placements had formal review arrangements. This continues to present a disparity in the arrangements for self-funded and social service arranged placements. There was inconsistency in terms of the signing and dating of assessments and care plans entries, although these were in place for some recent entries. The daily ‘diary’ entries in the care plans were detailed and were dated and identifiable by signature or initial. There was little written evidence in the care plan files examined to indicate that people living at the home had been involved in the formulation of the care plans. As at the last inspection, observation of staff and discussion with people living at the home indicates that a partnership in care exists between care staff and the people who live at the home, but this needs to be better evidenced by the details recorded in the care plans e.g. signature of people living at the home/representatives, where appropriate. People spoken to who lived at the home confirmed that staff are respectful of their privacy and dignity in their daily dealings with them. Staff were observed dealing appropriately with peoples’ needs, and all staff on the day of inspection were helpful and approachable. The acting manager stated that further staff are due to undertake formal training from an external source in respect of the administration and handling of medicines in February 2006. (Some of the staff team have already undertaken this training). This will provide further assurance that competent staff administer the medication. Old Vicarage, (The) DS0000052437.V270493.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): EVIDENCE: These standards were not inspected on this occasion. Old Vicarage, (The) DS0000052437.V270493.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): 16,18 There is a complaints procedure in place, with evidence to support that any concerns or issues will be acted upon within the appropriate timescales. The systems in place promote the protection of the people living at the home from abuse and neglect. EVIDENCE: The complaints procedure was displayed in the entrance area of the home; there is also a copy of this in the Statement of Purpose. A timescale of 28 days for response to complaints is now included within this. (This was a requirement from the previous inspection, which has now been met) Care staff at the home have undertaken Protection of vulnerable adults training one day course through Derbyshire County Council, this provides further assurance that people living at the home are protected from abuse and neglect. All people spoken to who lived at the home said that they were very satisfied with the quality of care, which was very good, and had no complaints. Old Vicarage, (The) DS0000052437.V270493.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): 24,25,26 People at the home live in safe, comfortable surroundings, which is kept in good order with good standards of hygiene and cleanliness maintained. EVIDENCE: A tour of the building was undertaken during the inspection. The home is attractive in appearance and the building is maintained to a good standard. The garden areas accessed by people who live at the home are enclosed to promote safety and are visually pleasing. The outstanding requirement to fit radiator guards in areas accessed by people living at the home has now been completed this promotes the safety of people who live at the home from the risk of heat injury. The water temperatures in two of the bathrooms were tested. The hot water temperature tested in one bathroom was higher than the recommended limit, and required adjustment to protect people living at the home from burns and scalds, this primarily relates to bathing and showering. This was discussed with the acting manager and the proprietor. The proprietor stated that the methods Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 14 of checking water temperatures in bathrooms will be reviewed, this demonstrates a commitment to address this in order to protect the people living at the home from burns and scalds. The standard of cleanliness within the home was evident on the day of inspection. The laundry must have floor finishes that are impermeable and wall finishes that are readily cleanable, (infection control measures) this was a requirement at the last inspection which has not as yet been met, this was discussed with the proprietor and deputy manager. Written infection control policies have been developed in part by the home, (a requirement of the last inspection) however the policies direct staff to follow the local agreed policies, which were not available at the home. This was discussed with the deputy manager. As stated in the last inspection report there is no evidence to suggest that current practice by staff is unsatisfactory, but the written documentation needs to support best practice. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 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): 28,30 A good level of care is provided by the care staff of the home, which will be enhanced further once staff are trained to the required level. EVIDENCE: Three of the current care staff had completed National Vocational Qualification (NVQ) Level 2 training. The acting manager stated that although not yet booked onto NVQ Level 2 training, another twelve care staff have an intention to commence this training in Spring 2006. (This was a requirement of the last inspection.) As stated in the last inspection report there is no suggestion that care staff are failing to meet the needs of the people living at the home, and all of the people spoken to that lived at the home stated they were very satisfied with the quality of care at the home. An induction programme was in place at the home and this was seen on the day of inspection, however this requires timescales to show when each area of the induction programme must be completed by, this was discussed with the acting manager. Old Vicarage, (The) DS0000052437.V270493.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): 31,33,37 The acting manager is accessible and responsive to the needs of the people living at the home, however people living at the home would benefit from having a registered manager undertaking the full range of legal duties and responsibilities. The systems in place promote the protection of people living at the home from health, safety and best interests perspectives. EVIDENCE: The acting manager has completed level 4 NVQ in care and is due to complete the registered manager’s award in mid-January. There is an outstanding requirement for the acting manager to apply for registration and an extended timescale was agreed at this inspection. The proprietor visits the home regularly and is involved on a day-to-day basis with decision regarding the home. Plans were in hand to increase the managerial and professional support Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 17 to the acting manager as part of the development of the group of homes owned by the proprietor. There was evidence to demonstrate that the registered proprietor makes regular visits to the home and therefore fulfils the regulatory responsibilities required. The acting manager stated that anonymous service user satisfaction surveys had been sent out to people living at the home, but there were no recent survey results available to view on the day of inspection. (This was a requirement from the previous inspection). Care planning documentation included reference to where people living at the home had brought in their own furniture and the inspector was shown an inventory format that will be used to record items in detail. The staff team had received some updates in safe working practices these included training in; moving and handling and fire safety. Further training is booked for staff in January and February 2006, this included; Food hygiene and Infection Control, once this training is completed, there will be further assurance that satisfactory efforts are being made to promote the health, safety and welfare of the people living at the home. Old Vicarage, (The) DS0000052437.V270493.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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 3 2 2 STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X 3 3 Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 19 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 1 Regulation 4 (1)) Requirement The Statement of Purpose must contain all the required detail (as per Regulation 4 (1) – Schedule 1) (previous requirement timescale 31 October 2005) There must be a service user guide that included a standard form of contract. A copy of the guide must be supplied to all people living at the home. (previous requirement timescale 31 October 2005) Risk assessments must be carried out where daily records clearly indicate that the behaviour of people living at the home presents a risk to themselves or to other people. All care plans entries, including reviews and risk assessments must be clear and detailed, and assessments must be dated. (previous requirement timescale 31 August 2005) There must be documentary evidence of to demonstrate that people living at the home are involved in the formulation of their care plans. (Previous DS0000052437.V270493.R01.S.doc Timescale for action 01/03/06 2 1 5 01/03/06 3 7 14 (2) b 28/02/06 4 7 14,15 31/01/06 5 7 15 (1) 31/01/06 Old Vicarage, (The) Version 5.0 Page 20 6 7 15 (2) (b) requirement timescale 31 August 2005) Care plans must be reviewed at least monthly and must be dated and signed to this effect. (Previous requirement timescale 31 August 2005) 31/01/06 7 25 13 (4) 8 26 13 (3) 9 26 13 (3) 10 26 18 (1) 11 28 18 (1) 12 31 8 (1,2) The temperature of water (where total or significant body immersion is possible) must not exceed 43 degrees centigrade at the water outlet. (Previous requirement timescale 31 July 2005) Laundry floor finish must be impermeable and the wall finish must be cleanable (previous requirement timescale 31 October 2005) The written infection control policies and procedures need to be developed to ensure that staff are directed to follow best practice (previous requirement timescale 31 October 2005). Induction training must comply with current standards (previous extended timescale 30 September 2005) A minimum ratio of 50 trained members of care staff must be achieved (NVQ Level 2 or equivalent) previous timescale of 31 December 2005 extended A manager must apply for registration with CSCI (Previous timescale 31 July 2005) 15/01/06 01/03/06 31/01/06 31/01/06 01/04/06 28/02/06 Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 21 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 7 Good Practice Recommendations Regular formal reviews for privately funded residents should be held. Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Old Vicarage, (The) DS0000052437.V270493.R01.S.doc Version 5.0 Page 23 - 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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