Inspection on 18/10/05 for The Old Vicarage

This inspection was carried out on 18th October 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 11/02/09

The Old Vicarage 12/02/08

The Old Vicarage 06/09/07

The Old Vicarage 20/02/07

The Old Vicarage 05/06/06

The Old Vicarage 26/10/04

The Old Vicarage 11/05/04

The Old Vicarage 25/11/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE The Old Vicarage Warren Road Hopton On Sea Great Yarmouth Norfolk NR31 9BN Lead Inspector Linda Wells Unannounced Inspection 18/10/05 10.15 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 The Old Vicarage DS0000027487.V249906.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. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Warren Road Hopton On Sea Great Yarmouth Norfolk NR31 9BN 01502 731786 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) Estateband Limited Mrs Jill Chaplin Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 20 older people of either sex may be accommodated Date of last inspection 19th April 2005 Brief Description of the Service: The Old Vicarage is a two storey detached Georgian house that provides residential care and accomodation for up to twenty older people. The home stands in its own grounds of approximately two acres, there is parking to the front of the home and the gardens are mainly lawned and are accessible by wheelchair. Service users at the home have the use of a passenger lift to the first floor and communal use of three lounges, a dining room, two bathrooms containing adapted bath, washbasin and toilet on each floor, two toilets on the ground floor and one toilet upstairs. There are nineteen single and one double bedroom which all contain a washbasin and the majority of the windows have been replaced with double glazed fitments. The home is situated in the village of Hopton-on-sea, between the coastal towns of Great Yarmouth and Lowestoft and is surrounded by caravans and sited in the centre of a holiday caravan village that is densly populated at certain times of the year. There are local amenities and the beach within walking distance of the home and a public transport service that provides a link to the main towns. The Old Vicarage DS0000027487.V249906.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 undertaken on the 18th October 2005 over five hours and was carried out as part of a routine inspection plan and as a follow up to an anonymous complaint investigation carried out on the 25th August 2005 when twelve requirements and three recommendations were made. Details of this investigation can be provided by CSCI on request. On the day of inspection thirteen residents were living at the home and residents were seen to be having a meal, sitting in the lounges or their bedroom listening to music, reading or watching television. The inspection took the form of a tour of the premises, individual discussion with four residents, two staff members, a senior staff member and the manager, group discussion with three residents, examination of care plans, records, certificates and compliance of requirements and recommendations from the last inspection and complaints investigation. What the service does well: What has improved since the last inspection? As a result of the complaint investigation and to ensure that the needs of residents are fully met and that they are protected, improvements in care practise, staffing levels, recruitment checks, quality of meals, activities and record keeping were seen. This is good. Residents have also benefited from a senior care staff member being on duty on each shift to ensure staff are supervised, three bedrooms being redecorated and refurbished and new bedding, replacement kitchen equipment and cutlery being purchased to make the home more attractive and better equipped. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 6 What they could do better: Residents said that they were happy living at the home, felt included and safe. However, although many of the requirements and recommendations from the last inspection and complaints investigation have been complied with there is still more to do. The following ten requirements and three recommendations were made to further improve the experience of living and working at the home for residents and staff. • The Quality Assurance system produced must be expanded to include the views and opinions of residents, staff members, visitors and health professionals on the standard of care, service and facilities provided at the home. Repeated requirement. The target of 50 of staff completing training to NVQ2 must be achieved to ensure staff members are fully equipped to meet the needs of all residents. Repeated requirement. A monthly review must be undertaken with each resident to ensure that they are consulted on the standard and plan of care they receive. Repeated requirement. Residents must be given a contract of the terms and conditions of living at the home to ensure that they are informed and a copy held in their plan of care. Repeated requirement. The arrangements at death to be recorded in the plan of care of each resident to ensure that their wishes are known and complied with. Medication administration records must be complete to protect residents. The hallway carpets must be replaced to make the home more attractive. Repeated requirement. The manager must complete the NVQ4 Registered Managers award to ensure her management and administration procedures protect residents and support staff members. Repeated requirement. All staff must complete adult abuse training to ensure residents are fully protected. The upstairs bathroom radiator must be guarded to protect residents. Repeated requirement. It is recommended that team-building exercises continue with staff to further improve the morale and team working of all staff members. It is recommended that the redecoration and refurbishment of the home be continued to make the home more attractive for residents. It is recommended that a cook be employed to ensure that good quality and specialist meals are provided. • • • • • • • • • • • • 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 DS0000027487.V249906.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 The Old Vicarage DS0000027487.V249906.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, 2, 5 The admission procedure and written information available has been rewritten and enables residents and staff to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose and Service User Guide were seen and found to contain relevant information. The manager said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. She said residents, their family or friends sometimes visited the home, that she often visited residents in their own home and that residents were admitted on a one-month trial basis. Residents had not been issued with a contract of the terms and conditions of living at the home and a requirement was repeated that a copy of a signed contract be held in the plan of care of each resident to demonstrate agreement. A resident who had lived at the home for two weeks said that he and his relative had visited the home prior to admission, had been given enough information about the home to help them make a choice, that staff had made him feel welcome and had helped him to settle into the home. The Old Vicarage DS0000027487.V249906.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, 11 The health, social and personal care needs of residents were met, they were well cared for but not all records were completed. EVIDENCE: Residents said they were well looked after and four individual plans of care were examined and found to contain relevant health, social and personal care information, care needs assessment, weight records, daily records, night care records, fluid chart, dietary needs, risk assessments, choices, past history, a photograph and visiting professionals. However, they did not contain monthly reviews with each resident or the wishes of each resident upon death. Two requirements were made that monthly reviews are carried out with each resident and the wishes of residents at death be recorded in their plan of care to demonstrate involvement, consultation and agreement of each resident on the standard and plan of care they receive and their funeral arrangements. Medication policies and procedures were seen, medication was stored correctly and a member of staff was observed safely administering medication but the records held contained six gaps in administration recording. A requirement was made that medication records be completed to demonstrate that medication is administered correctly and to protect residents. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 10 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, 14, 15 There are social and creative activities that provide interest and variety to residents and the quality and quantity of meals has improved. EVIDENCE: Residents said that their family and friends were always made welcome at the home and that staff and their key worker assisted and encouraged them to make choices. They said that they enjoyed the activities provided daily in the home and gave examples of going out with a member of staff, a music afternoon and buffet, bingo and looking forward to the Halloween evening. Records were seen to demonstrate that activities were provided and staff said that they did have time to provide one to one activities such as nail care or a walk for residents. The main meal and menus were seen and were balanced and varied. The budget had been increased resulting in better quality and quantity of fresh and frozen foods. Records showed that residents were given a choice and an alternative offered. Residents spoken to said that the meals had improved over the last month and staff members said that they had completed food hygiene training and prepared the breakfast and tea meal. The manager said that the home did not have a cook and therefore she was doing the cooking. A requirement was made that a cook be employed to ensure residents receive high quality and specialist meals to meet their needs. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 11 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, 17, 18 The home has a procedure on the protection of vulnerable adults that protects residents but staff training does not fully support the investigation of any cause for concern. EVIDENCE: One anonymous complaint had been received by CSCI about the home regarding care practice, management of staff, record keeping, morale and the conduct of the manager. This complaint was upheld in seven elements, partially upheld in five elements, unresolved in three elements and not upheld in three elements. The manager has made appropriate improvements and the home’s records demonstrated that a new complaints policy and procedure has been put in place and that any complaints made to the home are investigated and the appropriate action taken. The residents spoken to all agreed that if they had reason to complain they would speak to staff or the manager and all felt confident that the problem would be resolved quickly and to the satisfaction of all involved. Residents are able to exercise their legal rights and are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home. Records showed that not all staff had undertaken training in Adult Abuse and a requirement was made that this training be completed, by all staff, to help them recognise, prevent and deal with any potential abuse. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 12 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, 20, 21, 23, 25, 26 The standard of the environment within this home is mainly good but does not fully provide residents with an attractive, safe and homely place to live. EVIDENCE: A tour of the building revealed that residents live in a home that is decorated and furnished to a reasonable standard. Residents said that they benefited from a home that was comfortable, clean and tidy and this was found in all areas during the tour of the building. The manager outlined her plans to replace the hall carpets and to gradually redecorate and refurbish all areas of the home and although improvements had been made to the home some of the bedrooms were in need of redecoration, the radiator in the upstairs bathroom needed guarding and the hall carpets were in need of replacing. Two requirements were repeated and a recommendation was made that the carpets in the hallways are replaced, the radiator guarded and a continued plan of maintenance and redecoration is carried out, especially in some bedrooms, to ensure that residents are fully protected and the home is attractive in all areas. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 13 Residents were seen to have personalised their bedrooms, specialist equipment was provided and each floor of the home had adequate bathrooms and toilets that were adapted to suit the needs of the residents. The Old Vicarage DS0000027487.V249906.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, 29, 30 The needs of residents are met, staff members are competent and the procedure for the recruitment and training of staff provides safeguards to offer protection for the people living in the home. EVIDENCE: Residents said that they were well cared for and the staff spoken to said that there were enough staff on duty if all shifts are fully covered. The two staff members spoken to said that they are supported by the senior care staff and the manager, handover, staff meetings and supervision and demonstrated that they were aware of their role and responsibilities. Records showed that residents were protected by the staff recruitment checks that had been carried out. CRB checks, references, personal details, a photograph and proof of identity, were seen and held in the file of each staff member. Records demonstrated that staff members had a mix of experience and skills and the manager said that four staff members had completed NVQ2 and one was about to commence NVQ2 and one NVQ3 training. Improvements had been made in the basic training of staff and certificates showed that induction, foundation and updated training programs were undertaken by all staff. A requirement was made that at least 50 of staff undertake NVQ2 training to ensure that the needs of residents are fully met and a recommendation was made that staff continue to attend team building sessions with the manager to further improve communication, cohesiveness and morale. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 15 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, 34, 35, 36, 37, 38 The manager has made improvements and is supported by the senior staff in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care. EVIDENCE: The manager has over twenty years experience of working in the care setting and has been in post for one year. She has inherited poor systems and practise and has been working to make improvements to the standard of care provided, record keeping and the environment. Part of the anonymous complaint received by CSCI criticised her management conduct and was partially upheld but since the complaint she has made improvements to her management style that have benefited residents and staff and the smooth running of the home. A requirement was repeated that the manager complete the NVQ4 Registered Managers award to ensure she has the necessary knowledge and is fully equipped to manage a residential care home. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 16 Residents and staff members said that improvements had taken place over the last month, that the home was now run in a better way and that the manager was supportive, approachable and gave clear direction. Records demonstrated that the management, accounting and financial administration procedures carried out in the home offer safeguards and protect residents. A quality assurance system has been produced for residents and a requirement was made that it be expanded to include the views and opinions of residents, staff, visitors and health professionals on the quality of care, service and facilities provided at the home. Policies and procedures have been produced and were seen on all aspects of the home and service provided. The records held were found to promote and protect the rights and best interests of each service user. An improved system of supervision and record keeping has been put in place and the handover, staff meeting minutes and supervision records demonstrated that staff members worked as a team, were supported and regularly supervised by the manager and senior care staff to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs were identified, clarified and reviewed. The servicing and testing of all equipment had been carried out and relevant and timely certificates were held to ensure that the health and safety of residents is protected. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 17 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 3 2 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 2 3 X 3 X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 3 3 3 The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 18 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 OP2 Regulation 5.1.b Requirement Timescale for action 31/12/05 2 OP7 3 OP9 4 OP11 5 OP18 6 OP19 7 OP19 The registered person must ensure that a copy of the contract signed by each service user is held in their plan of care. (Previous timescale of 30th June 2005 not met) 15.2.b The registered person must ensure that monthly reviews are undertaken with service users. (Previous timescale of 30th May 2005 not met) 17.1.sch 3 The registered person must ensure that medication administration records are completed. 12.3 The registered person must ensure that the arrangements and wishes at death are recorded for each service user. 13.6 The registered person must ensure that all staff complete training in the prevention of Adult Abuse. 23.2 The registered person must replace all carpets in the hallways. (Previous timescale of 31st August 2005 not met) 13.4.c The registered person must ensure that the radiator in the DS0000027487.V249906.R01.S.doc 31/12/05 01/12/05 31/01/06 31/12/05 31/03/06 01/02/06 The Old Vicarage Version 5.0 Page 19 8 9 10 OP28 OP31 OP33 18.1.c.i 10.3 24.1.a upstairs bathroom is guarded. (Previous timescale of 31st August 2005 not met) The registered person must 31/03/06 ensure that 50 of staff complete training to NVQ2. The registered person must 31/03/06 complete the NVQ4 Registered Manager training. 31/12/05 The registered person must ensure that the quality assurance system in place includes the opinions and views of visitors and healthcare professionals. (Previous timescale of 31st August 2005 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP19 OP30 Good Practice Recommendations It is recommended that a cook be employed to ensure good quality and specialist meals are provided that meet the choice and preferences of service users. It is recommended that the redecoration and refurbishment of the home, especially in the bedrooms, continues to make the home attractive in all areas. It is recommended that team-building exercises continue with staff members and the manager to further improve communication, cohesiveness and morale. The Old Vicarage DS0000027487.V249906.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027487.V249906.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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