Inspection on 21/06/05 for The Old Vicarage

This inspection was carried out on 21st June 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

The Old Vicarage 23/11/05

The Old Vicarage 09/01/05

The Old Vicarage 11/08/04

The Old Vicarage 13/11/03

The Old Vicarage 03/06/03

The Old Vicarage 28/01/03

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

CARE HOME ADULTS 18-65 THE OLD VICARAGE Parsonage Lane Hungerford Berkshire RG17 0JB Lead Inspector Rhian Williams-Flew Unannounced 21 June 2005 @ 12:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Parsonage Lane Hungerford Berkshire RG17 0JB 01488 683634 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) Cornerstone Housing Mr Gary Devlin Care Home 11 Category(ies) of Learning Disability LD registration, with number of places THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 09/01/05 Brief Description of the Service: The Old Vicarage is a care home providing personal care and accommodation for up to 11 adults with learning difficulties. Mr and Mrs Childs own the home. The business name is Cornerstone Housing. The home is situated near the Parish Church of Hungerford and is a short walk from the main shopping area of the town. Access to bus and train services is close by. The home consists of a large house with seven bedrooms, this is known as The Old Vicarage. All of the rooms in the main house are single occupancy. In addition, there are three buildings which are annexed to the main house. One of these buildings is called The Lodge, which accommodates one resident. Another building is called The Coach House which can accommodate two residents; presently one resident lives here. The third building is called Parsonage Cottage and accommodates one resident. All of the residents receive support from the same staff team who are available throughout the 24 hours of the day. Usually there are no waking night staff unless there is a specific need. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 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 occurring on a weekday between 1200 and 1850 hrs. The Registered Manager was present throughout the inspection. Six of the nine service users were spoken with. Two members of staff were spoken with in private. The focus of the inspection was on the environment, staffing and management of the home. What the service does well: What has improved since the last inspection? Care managers have purchased additional staff time for individual residents. This has had a significant impact on the quality of these resident’s lives. It enables them to do more individual activities on a as and when basis. The benefits of this individual attention have been significant. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 6 Gas-fired central heating has been installed in the annexed buildings (as an alternative to electric radiators). This will be a considerable benefit for the residents. 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 H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None No judgement made on this inspection. EVIDENCE: None of these standards were inspected on this occasion. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None. No judgement made on this inspection. EVIDENCE: None of these standards were inspected on this occasion. A full review of all these standards took place at the last inspection on 9 January 2005 and all were met. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None. No judgement made on this inspection. EVIDENCE: None of these standards were inspected on this occasion. A full review of all these standards took place at the last inspection on 9 January 2005 and all were met. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None. No judgement made on this inspection. EVIDENCE: None of these standards were inspected on this occasion. A full review of standards 18 & 19 took place at the last inspection on 9 January 2005 and they were met. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The complaints policy and procedure in the home is robust and effective. There is a weakness in the knowledge of some staff with regard to the protection of vulnerable adults. EVIDENCE: There has been one complaint recorded regarding the service since the last inspection. This concerned a complaint made by a staff member regarding remarks made by a resident. The investigation by the Registered Manager was conducted appropriately. The Registered Provider reviews the complaints log during his regular unannounced monthly visits to the home, this is good practice. The home does have a policy with regard to the protection of vulnerable adults and whistle blowing. They also have access to the local authorities interagency guidance on the protection of vulnerable adults. The majority of staff in the home need to update their training with regard to protecting vulnerable adults. Evidence was seen that seven places have been applied for. The staff hope to attend such a training course in either August or October. In discussion with some members of staff they were not able to clearly demonstrate their understanding of the correct procedure should a vulnerable adults issue be disclosed to them or they witnessed such an event. This was discussed with the manager who agreed to address the issue of the next staff team meeting in addition to staff receiving the planned training. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 & 30 This home provides ample space and access to good facilities for the residents. With noted exceptions the home is well maintained and clean. EVIDENCE: The main house and the three annexes (collectively known as The Old Vicarage) are suitable for their stated purpose. They are in keeping with their local community. The home is well maintained and provides good facilities for all the residents who live there. There were exceptions to this usual high standard in one of the resident’s rooms and the floor covering in one of the bathrooms. Both areas are in need of refurbishment. The Registered Manager has confirmed that these areas are next on the list of refurbishment. These should be viewed as a priority. At present, the three annexes are having new roofs fitted and having gas central heating installed. The individual room spaces for all the residents are suitable for their needs. They each have the required furnishings and fittings. Since the previous inspection the home has registered an additional room for use (at present it is unoccupied). The Registered Provider has confirmed that the room provides THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 14 floor space of at least 12 square metres. The room has its own en-suite shower, toilet, wash hand-basin and vanity unit. The home has sufficient numbers of toilets and bathrooms for residents use. With the exception of the previously mentioned areas, the home is clean and hygienic. The laundry facilities in the home are in an external building adjacent to the home. The washing machines have specific programmes to meet disinfection standards should they be required. All the resident’s laundry is carried to this area enclosed in laundry baskets. It was noted that some of these laundry baskets were in need of replacement and this was advised to the Registered Manager. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36. This home has robust procedures for recruiting staff. The home is also committed to supporting the training needs of staff and their supervision. These issues demonstrate that the home is committed to affording the residents protection. EVIDENCE: All members of staff have clearly defined job descriptions and from conversations with staff they had a clear understanding of their roles and responsibilities. All of the care staff with the exception of one newly appointed member have achieved their NVQ 2 and above. Each member of staff has a training profile to identify their training needs. The deputy manager has responsibility for addressing the training needs of staff. She was spoken with regarding some of the deficits staff have in their training needs (particularly with regard to mandatory training) and she was able to evidence that she has applied for courses to address these deficits. Some members of staff will also be attending a specialist course on epilepsy and medication training in the near future. Discussions were held with the manager and the deputy manager with regard to ensuring that staff have access to other specialist training to increase their knowledge with regard to specific syndromes. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 16 The staffing rotas were reviewed and it was noted that there are sufficient members of staff on duty at all times to support the resident’s needs. In conversations with the residents they confirmed that there are always members of staff available to help them and they know who is going to be on duty at each change of shift. The recruitment records of three members of staff were reviewed and they were found to be recruited, as required by the regulations. The Registered Manager was advised that he reconsider the format of the reference requests for new applicants, which he agreed to do. The supervision records of two staff were reviewed and were found to be upto-date and supervision is being held regularly. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41, 42 & 43. This is a well managed home. The manager ensures that the health, safety and well being of the residents and members of staff are safeguarded. EVIDENCE: The Registered Manager manages the home to reflect the regulations and standards required. He has good procedures in place that are effective and ensure that the home is well managed. In conversations with the residents and members of staff who were spoken with, all confirmed that the manager gives clear leadership and is approachable. The home does have effective quality monitoring systems in place. The majority of the residents who live in this home are able to voice their likes and dislikes well. In conversation with them none of them felt hesitant about approaching the manager or the members of staff if they wished to comment THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 18 on anything. The majority of residents also have good support from their family, friends and advocates in the community. The residents are familiar with the inspection process and are always willing to share their views and comments with the Inspector. Records appertaining to the running of the home and the residents who live in the house are stored securely. Samples of records, which are required to be kept, were reviewed. Incident records were well completed and filed appropriately. Accident records are kept and are stored as required by the Data Protection Act. The manager was advised that he record an index of the accident log numbers, in a central place that only he has access to, so that records can be easily referenced. The log books for the fire safety checks were reviewed. It was noted that deficits were being recorded but there was no audit trail as to how or when the deficits had been addressed. The manager undertook to review how the fire checks are recorded and how actions are implemented. Risk assessments need to be completed for the radiators in the home. Once the risk assessments have been completed (and depending on outcome) actions will need to be taken to reduce the risks. As previously mentioned there are deficits for some staff in the mandatory training required. Training sessions are planned in the near future. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 2 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 THE OLD VICARAGE Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 2 x H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 23 Regulation 13 (6) Requirement All members of staff must be aware and familiar with the procedures and actions with regard to vulnerable adults procedures. All staff should also receive training in this area. One residents room and the flooring in a bathroom (identified to the manager) must be refurbished. Risk assessments must be completed for all radiators in the home and action taken on the outcome of these assessments. Timescale for action 31.08.05 2. 26 16(2) (k) 15.09.05 3. 4. NA 42 13(4)(c ) 31.07.05 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 42 Good Practice Recommendations The fire check log book need to record any actions taken on deficits identified. THE OLD VICARAGE H52-H01 11143 Old Vicarage V222364 210605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 1015 Arlington Business Park Theale Berks RG7 4SA 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 H52-H01 11143 Old Vicarage V222364 210605 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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