Inspection on 05/12/05 for The Old Vicarage

This inspection was carried out on 5th December 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 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 25/05/07

The Old Vicarage 15/06/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings 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 Vicarage Lane Tilmanstone Deal Kent CT14 0JG Lead Inspector Mrs Penny McMullan Announced Inspection 5th December 2005 10:00 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 DS0000064625.V258590.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 DS0000064625.V258590.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Old Vicarage Address Vicarage Lane Tilmanstone Deal Kent CT14 0JG 020 8462 1870 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) Mr Pathmanathan Elango Mrs Rajakala Elango Mrs Janet Swanborough Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2005 Brief Description of the Service: The Old Vicarage provides residential care to 39 older people. The Home comprises a large, extended detached house located in a rural area between the coastal towns of Dover and Deal. There is a shaft lift, with four en suite bedrooms. There are no specialist services provided on site but the Home accesses local primary healthcare services such as the GP and District Nurses. Facilities such as a hospital, shops library, theatres etc are within a fifteen minutes drive and the Home has an appropriately adapted minibus. There are spacious well maintained garden areas including a pond where residents enjoy sitting especially in the summer months. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mr and Mrs Elango purchased The Old Vicarage and were registered with the Commision on 16 June 2005. Mr and Mrs Elango and the Registered Manager Mrs Janet Swanborough have a good understanding of what needs to improve in the home. Some of the requirements and recommendations from the last inspection have been complied with and progress has also made to ensure the home meets all of the national minimum standards. The Registered Providers are committed to improving the environment and the home is in the process of implementing a redecoration plan and ordering new chairs for the lounge. The inspection took place over 7 hours and discussion took place with Mrs Janet Swanborough, Registered Manager, a group of eight staff, four relatives and 10 service users. Mr and Mrs Elango were also visiting the home for part of the inspection. The response to the postal survey was very good with comment cards received from 12 residents, 8 General Practioners, 6 Health and Socail Care Professionals and 26 relatives. Overall the general opinion of the home is very good with all comments confirming they are happy with the overall services provided in the home. There were some comments made with regard to activites in the home, staffing numbers, residents smoking facilties and the new system for residents to purchase personal items. Further specific detail of these comments have been added throughout this report. What the service does well: Residents said that the home caters for their needs and the staff is polite and kind. One resident said that the staff always listen and do everything they can for me. Residents comments from the surveys were as follow: ‘the home encourages visitors, it is warm and staff respond well to your needs’, ‘staff are polite and always knock on my door before coming in’, ‘the food is very nice and you can The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 6 choose from the menu’, ‘I am very satisfied living here and have no complaints’, and ‘the staff wonderful, really caring’. Relatives comments include ‘The home is always warm and welcoming,’ the staff understand my father’s needs’, ‘the home is well run home with a lovely atmosphere, good humoured staff and an approachable manager’. A visitor remarked that the home is always clean, tidy, warm and comfortable, my friend is very happy here. Overall there are positive comments from the general GP’s and health care professionals. Staff says they have good team work in the home and work hard to ensure the needs of the residents are met. What has improved since the last inspection? What they could do better: To ensure that all residents have the new format of the care plan completed together with implementing monthly reviews and ensure resident participation and signing of the plans. A requirement has been made in this report. To ensure the complete refurbishment of the medical room is completed and countersign written/typed in entries on mar sheets. A requirement has been made in this report. To review staffing levels especially in the afternoons to ensure enough staff is on duty to meet the needs of the residents. One health care professional felt the home did not always have the staff resources and further information is provided in this report around staffing numbers. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 7 To provide and update all of the mandatory training for all staff and ensure staff supervision is kept up to date. A requirement has been made in this report. To ensure that the planned programme of refurbishment and maintenance is ongoing to improve the environment for the residents. A recommendation has been made in this report. To continue to fit radiator guards whilst maintaining an attractive environment for residents to live in. A recommendation has been made in this report. 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 DS0000064625.V258590.R01.S.doc Version 5.0 Page 8 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 DS0000064625.V258590.R01.S.doc Version 5.0 Page 9 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): 1,6 The homes Statement of Purpose and Service User Guide provide Service Users and prospective Service Users with detailed information, however minor amendments are required to fully meet the standard. EVIDENCE: The Statement of Purpose and Service User Guide are in place and have been updated to reflect the new ownership of the home. The documents are detailed and thorough however some of the information in the Service User Guide belongs in the Statement of Purpose. The documents need to be reviewed to ensure that the relevant information is provided in the appropriate document. Standard 6 is not applicable to this home. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 10 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, The new format of care planning will ensure that there is a consistent plan in place however the lack of monthly review could put residents at risk of not having their care needs met. The systems for medication administration are good, however, the lack of checking written information on medicine administration sheets is required to minimise the risk of recording errors in medication. EVIDENCE: The home is currently implementing a new format in the care plans. The new format covers all information with regard to health and social care needs. Some relatives/residents have been involved in the care planning process and the home needs to ensure that the plans are singed. Moving and handling risk assessments have been carried out and bathing facilities have been reviewed to ensure resident’s independence is promoted. Accidents and incidents are being recorded in the daily logs and recording and monitoring has improved. The home must ensure that the care plans are reviewed on a monthly basis. The new format of care plan needs to be introduced for all The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 11 residents in the home and the Registered Manager is working towards achieving this end. A requirement has been given to address these issues. The home has the necessary equipment to support residents with their moving and handling needs and all health care needs are monitored through the care plan. A new hoist has recently been purchased for the home. The District Nurse and other health professionals when required support the home. The home has liaised with the Community Physiotherapy Team for a programme of fun and exercise and is hoping to introduce this exercise session on a weekly basis. The storage and security of medication has been reviewed and the home is in the process of finishing the room to ensure the safe storage of medication. There are currently no controlled drugs but storage of controlled drugs may need to be considered in the future. The home has also purchased a small lockable drug fridge, which will be installed on completion of the works. The documentation for receipt, recording and the return of medication is in good order, however typed entries on the mar sheet need to be countersigned. A requirement has been made in this report. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 12 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 The home has implemented a planned activities programme to meet the needs of the residents. The home has implemented a new financial support system to promote resident’s autonomy and choice. Arrangements are in place for advocacy services to be accessed. The home provides a well balanced nutritional diet and the overall provision of meals is of a good standard. Service users confirmed choice and variety of meals and special diets are catered for. EVIDENCE: Residents, relatives and staff all say that the activities have improved in the home. The planned activities for the month were on display on the notice board. Activities were discussed at the last resident meeting on 1 December and the entertainment has been arranged for Christmas. During the morning a pantomime was taking place and residents commented on how much they enjoyed it. It is the homes policy not to handle resident’s monies and families, representatives or Solicitors help residents with their finances. The home has The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 13 reviewed their systems with regard to the provision of personal items such as toiletries ensuring that all items are receipted and recorded. Relative feedback indicates mixed views with three saying that they felt the new system were bureaucratic. The new system ensures that service users are able to have as much autonomy and choice over their purchases and ensures that the home receipts all transactions as per the regulations. Advocacy information is on display and although some residents were aware of their paperwork residents spoken to did not wish to see their personal records. Residents said that overall the food was good, the menu is on display and they are offered alternatives. The meal was appetising and well presented and residents were offered second helpings and had a choice of juice or wine with their meal. Breakfast is a choice between porridge and cornflakes and sometimes a cooked breakfast is offered. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 14 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 The home has a satisfactory complaints system and residents feel that their views are listened to and acted on. Staff are aware of Adult protection issues and have received training to protect residents from abuse. EVIDENCE: The complaints procedure is on display in the home and residents spoken to say they had no reason to complain but if they did they would speak to a member of staff or the Manager. The home has a record of complaints and there has been one complaint since the last inspection, which has been actioned and resolved. The home has an Adult Protection Policy and Whistle blowing Policy. The Registered Manager is an Adult Protection trainer and all staff has now received training. CRB and POVA checks are in place and resident’s personal possessions are also recorded. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 15 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): 19,21,25,26 The new Owners and Registered Manager have a good understanding of the areas in which the home needs to improve. The provision of toilet facilities is satisfactory however further review is required to ensure easy access to residents. Bathing facilities have now been reviewed to promote resident’s preferences and choice to maintain their independence. The ongoing fitting of the current design of radiator guards will provide residents with a pleasant environment to live in. Laundry facilities are satisfactory and policies and procedures are in place to control the risk of infection. EVIDENCE: The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 16 There are areas of the home, which require redecoration, and the Registered Providers and Registered Manager are aware of these issues and have a planned programme of maintenance and are hoping to start the redecoration in the New Year. The conservatory was scheduled for repair this week and the changes to the medical room is in process. There have been comments with regard to the lack of a smoking room in the home both from residents and relatives. The home has provided an outside area and service users spoken to said that they did not mind using this area however this may be a problem in bad weather. The home is currently consulting the Fire Officer with regard to the provision of a room or closing in the identified area outside. The home must ensure that residents and prospective residents are advised of the smoking rules within the home and this must be clearly identified in the Statement of Purpose, Service User guide and contract. Toilet facilities are close to the lounge and dining room however they can be restricted in busy times and although access for wheelchairs is in place this is a tight area for space. The home is reviewing toilet facilities to address this issue. The bathing facilities have been reviewed and there are now additional bathrooms in use, promoting resident’s choice and independence. Some new radiator guards have been fitted which are pleasant to look at and in keeping with a homely environment. The home needs to continue to provide guards for the radiators and pipework. A recommendation has been made in this report. There is a separate laundry room with a sluicing facility in the washing machine programme. Hand washing facilities are provided in the laundry and the walls and floor is easily cleaned. Residents said that the laundry service was very good. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 17 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 lack of staff cover will result in resident’s health and social care needs not being fully met. Arrangements are in place to ensure that residents are supported and protected by the homes recruitment policies and procedures. The home has a training and development programme, and induction training is in place however the lack of mandatory training for all staff puts residents and staff at risk. EVIDENCE: Two residents and three comments from relatives say that the home is sometimes short staffed. Relatives say especially at weekends. The rota shows four care staff on duty in the morning and the home endeavours to provide five if possible and three in the afternoon and four when available. There is no one permanently rostered to help with tea in the afternoon and if only three members of staff are on duty there is not enough care staff to ensure the needs of the residents are met. There are currently six residents who have been assessed as requiring two carers. The home must review the staffing levels to meet the assessed needs of the residents. There is experienced qualified staff as well as new recruits who are in the process of commencing NVQ qualifications. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 18 Residents and relatives say that carers are kind, very good, worked hard and are responsive to their needs. A requirement has been made in this report. All of the necessary checks for safe recruitment practices are in place and staff spoken to confirm that an induction training programme is in place. The home has a training matrix and Induction training is in place, however they must provide all mandatory training to all staff. Although training has been booked there are still considerable numbers of staff that require attending this training. A requirement has been made in this report. Staff say that the training has improved since the last inspection and there are more courses booked in January 2006. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 19 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): 33,35,36,38 The system for resident consultation is in place to ensure resident views are considered and the home is run in their best interests. The home has implement an effective financial system to maintain any transactions to support residents with their finances. Staff supervision is taking place, however this was not up to date to ensure that staff are valued and supported. The home is endeavouring to provide a safe environment for residents, however the lack of mandatory training and environmental risk assessments puts service users at risk. EVIDENCE: The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 20 A quality assurance survey was carried out last November, and the results have been summarised and forwarded to the Commission. The Registered Providers are carrying out Regulation 26 visits and residents meeting were held on 1 December 2005. Currently relatives/representatives or Solicitors support the service users with their finances. The home has introduced a new system where any resident transactions, which may take place, are noted and a record of receipts is maintained. Two members of staff confirmed supervision had taken place but it is not up to date for all staff. The home must ensure that supervision is provided at least six times per year for all staff. A requirement has been made in this report. Some mandatory training has been provided and further training has been booked. The home still has a considerable amount of staff that requires Health and Safety, Food and Hygiene, First Aid and Infection Control Training. A requirement has been made in this report. All of the safety and maintenance checks have been carried out. Legionella test was completed and the electrical installation check was being carried out. Environmental risk assessments are being carried out and need to be completed for all areas of the home. The driveway in the front of the home is in need of repair and lighting around the staff car park needs to be reviewed. Accidents/incidents are being recorded but not monitored with action taken. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 21 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 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 3 x x X 2 3 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 2 x 2 The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 22 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 OP1 Regulation Sc 1, 4,5 Requirement To review the Statement of Purpose and Service User Guide to ensure the correct information is provided in the right document To ensure that residents sign their care plan and the plans are reviewed on a monthly basis The home must complete the refurbishment of the medication room and ensure typed entries on mar sheets are countersigned to minimise the risk of error To review staffing levels to the assessed needs of the residents To provide and update all staff with mandatory training The home must ensure that supervision is kept up to date and all staff are supervised at least six times per year Timescale for action 31/01/06 2 3 OP7 OP9 15 13 31/12/06 31/12/05 4 5 6 OP27 OP30OP38 OP36 18,19 12,13,18 18 09/12/05 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 23 No. 1 2 Refer to Standard OP19 OP25 Good Practice Recommendations To ensure the planned maintenance programme is ongoing To continue to implement radiator guards and review existing guards which in some cases still pose a risk to residents (This programme of providing guards is ongoing and the home is working through all parts of the environment) The Old Vicarage DS0000064625.V258590.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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