Inspection on 12/05/05 for The Old Vicarage

This inspection was carried out on 12th May 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

The Old Vicarage 03/07/08

The Old Vicarage 17/04/07

The Old Vicarage 06/12/05

The Old Vicarage 03/11/04

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 The Old Vicarage The Old Vicarage Ivy Bank Road Sharples Bolton BL1 7EQ Lead Inspector Rukhsana Yates Unannounced 12 May 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. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address The Old Vicarage Ivy Bank Road Sharples Bolton BL1 4QR 01204 594736 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) Macdonald Care Limited Mrs S G Macdonald CRH Care Home 19 Category(ies) of OP Old Age : 19 Places registration, with number of places The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: That the home is registered for a maximum of 19 service-users to include: Up to 19 service-users in the category of OP (Old Age not falling into any other category). That the service should employ a suitably qualified and experienced Manager who is registered with CSCI. Date of last inspection 03 November 2004 Brief Description of the Service: The Old Vicarage is a privately owned care home offering residential care and support for up to 19 older people. One of the owners is responsible for the day to day management of the home. It is situated about two miles from the centre of Bolton, and is close to bus routes, shops, pubs and other amenities. There are two floors, with a lift to the first floor. The home has 13 single rooms and 3 shared rooms. 11 rooms have en-suite facilities. The grounds include a car park and large, well maintained gardens. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over 8 hours. Most of the day was spent talking to 2 residents on their own and 6 others in a group, a district nurse, two staff members and the manager. Lunch was taken with residents. The remaining time was spent looking around the home and some bedrooms, and reading care plans, staff files and other paperwork relating to the care and safety of residents. What the service does well: What has improved since the last inspection? The choice of activities has improved since the last inspection. Staff members are keen to look at new ideas and places for trips out, providing new experiences for some residents. Plans to organise a barge trip is one example of this. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 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. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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 The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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 Each person considering moving to The Old Vicarage has their needs assessed, and is given information about the home, before admission. The admission process ensures that new residents know what to expect of the service from the outset. EVIDENCE: The admission process is described in the home’s “Statement of Purpose”. It states that an assessment is carried out before admission, and then a full care plan drawn up in consultation with the resident or their representative. Records show that this process is followed. The files of residents new to the home include an initial assessment and a more detailed care plan covering a wide range of information that care staff need to know. Residents or their relatives have signed to confirm their agreement to the care plan. Two residents said that relatives had chosen this home for them, having visited others in the area, and that it was a very good choice. They spoke highly of the manager’s and carers’ knowledge and understanding of their needs. Staff members demonstrated a good understanding of the individual needs, personalities and preferences of people admitted to the home. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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’s personal, health, social care needs and risk assessments are well reflected in their care plan. Medication arrangements are safe, although medication records must be accurately completed to remove the risk of mistakes. Changes in need and actions for care staff could be better reflected in monthly reviews so that residents’ well-being is effectively monitored. EVIDENCE: Care plans cover a wide range of relevant topics and include useful information about residents. They describe personal care and health needs, individual dietary preferences, daily routines, social and religious needs. Interests are well detailed. For example, a liking for specific programmes and music is recorded, rather than a general comment about enjoying television and radio. Risk assessments cover moving and handling, skin care and other areas as necessary. Daily reports and monthly reviews are completed for each resident. Both use general phrases to describe residents, such as “frustrated”, “anxious” or “more confused than usual”. These should be more specific. Details about the action to be taken to address these are not clear. Specific actions should be recorded and reviewed each month so that the effectiveness of those actions can be properly monitored. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 10 Residents said that the care is good and that the home looks after their health. A visiting District Nurse said that she had not had any concerns about the home in all the years she had visited, that the manager is approachable and staff are “cheerful and friendly.” She described effective communication with staff who have a “good knowledge of skin care and of residents’ needs”. Records show that healthcare needs of residents are met. Medication storage arrangements are safe, risk assessments are completed for those able to selfmedicate and staff receive training in safe practices. There were occasional gaps in the administration records. Care must be taken to keep accurate records of medication given to ensure that residents are given the medicines they need at the correct times. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 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 standard(s) 12 and 15 Residents’ needs and preferences are reflected in a good variety of activities offered and enjoyed at the home. Residents feel their daily routines are flexible and are pleased with the choice and quality of meals. EVIDENCE: Residents said they have a choice in their daily routines, including what time they get up and go to bed, where to spend their time, and which activities to take part in. Records and discussions highlighted a good range of indoor pastimes. These include crafts, exercise, board games, manicures, quizzes, card games, relaxation, reminiscence and seasonal celebrations. Residents are enthusiastically supported in taking local walks and joining in with organised day trips and holidays. Residents consulted said they don’t get bored and that they are encouraged to keep active. During lunch, it was apparent that residents enjoy good quality meals in pleasant surroundings. Care staff provide sensitive assistance and encouragement where needed. The dining room is homely and bright. The lunchtime meal consists of three well-presented courses, a choice is offered at each meal and menus are varied and nutritious. Residents said that they are asked to make their choice of meal in advance, and each person consulted was very positive about all aspects of the food. The kitchen is well organised, with catering and care staff having a good knowledge of people’s dietary needs. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 12 The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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) 6 Residents and their relatives feel able to air their views, confident that the manager and staff will listen and respond to their satisfaction. EVIDENCE: Each resident, or their family, has been given a copy of the complaints procedure. From observations and discussions, it was clear that people felt comfortable in raising any issues informally with staff members or the manager. There have been no complaints received by the home or the CSCI since the last inspection. One group of residents, commenting on meals, said “If we say we don’t like something, they listen to us and change it”. The views of residents were also reflected in comments made by a visiting district nurse who said that “staff are cheerful and helpful and the manager is very approachable. You can raise any issues at any time and know they will be dealt with.” The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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 and 26 The Old Vicarage provides a clean, comfortable, well-maintained environment for residents. The home and grounds are pleasant and safe, but some doors need attention to make them effective in the event of a fire. EVIDENCE: Residents said they are very satisfied with the standard of cleanliness and décor throughout the home. Bedrooms and communal rooms are homely and comfortable, with redecoration taking place when necessary. The home has a large lounge, an attractive dining room and conservatory. There are large, well maintained garden areas accessible to, and enjoyed by residents. The home has a passenger lift and a range of aids and adaptations to help residents to maintain their independence. These include grab rails and assisted baths and showers. Regular checks are carried out throughout the home to make sure the environment is safe. However, there is a need to ensure that all fire doors are effective and close properly to maximise safety for residents in case of a fire. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 15 The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 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) 29 and 30 The staff group has the knowledge, skills, training and management support it needs to effectively meet the care needs of residents. The careful recruitment process ensures that care staff employed are suitable, and the welfare of residents protected. EVIDENCE: Residents spoke highly of the manager and staff, describing a high level of confidence in their ability to provide a good quality of care. Staff showed sensitivity and respect when talking to residents. Staff members interviewed confirmed that they have received a wide range of training relating to their work, and that they have developed their skills and abilities as a result. One staff member listed a number of positive factors that allow the staff team to provide a good service. These included “a keyworker system that works so that responsibilities are clear, good organisation, lots of training, appraisals every two months, a good atmosphere, time to talk to residents and approachable people”. Residents said they live in “a very nice home with very good staff”. Staff files show that the manager carries all necessary checks before employing a new staff member. Once employed, staff receive the training and support they need to carry out their role. Anyone without NVQ qualifications are encouraged to work towards them with the aim of improving staff practices for the benefit of residents. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 17 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 The manager seeks and records the views of residents, and now needs to produce a plan that will show residents and others how their views are being used to improve the service. The health and safety of residents and staff are promoted through safety checks and staff training. EVIDENCE: Questionnaires for residents and visitors have been used to obtain their views about the home, and there are regular staff and residents’ meetings. It was clear that the manager cares about quality and positive experiences for residents. However, there is a need to bring together the views of residents, relatives and others, such as social workers and health professionals and produce a quality development plan. The plan should be in a format that residents and others understand, and show how the home is using views to improve the service each year. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 18 The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 19 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 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x x x x x The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 20 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. 2. 3. Standard 9 19 33 Regulation 13 23 24 Timescale for action Medication records must be 12 May accurately completed. 2005 Fire doors must be made 10 June effective. 2005 The quality assurance and 12 monitoring system must be September developed to include the views of 2005 stakeholders. The information to be collated to inform an annual development plan for the home.(Previous timescale of 31.3.05 not met) Requirement 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 In respect of care plans, specific actions should be recorded and reviewed each month so that the effectiveness of those actions can be properly monitored. The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Turton Suite, Pargon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 The Old Vicarage F56 F06 S61207 Old Vicarage V216967 120505 Stage 4.doc Version 1.30 Page 22 - 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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