Inspection on 07/11/05 for The Old Vicarage

This inspection was carried out on 7th November 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Vicarage 27/06/07

The Old Vicarage 04/07/06

The Old Vicarage 19/07/05

The Old Vicarage 24/02/05

The Old Vicarage 01/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Old Vicarage (The) Market Place Riddings Alfreton Derbyshire DE55 4BQ Lead Inspector Jill Wells Unannounced Inspection 7th November 2005 14:00p Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Old Vicarage (The) DS0000020065.V265665.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Vicarage (The) Address Market Place Riddings Alfreton Derbyshire DE55 4BQ (01773) 607479 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 Raymond Miles Mrs Pauline Ann Miles Jane Anne Selby Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: The Old Vicarage is a large old building in a pleasant area. It is well decorated and maintained. The home is within a short distance from local shops and a park. The Registered Providers offer places for up to 10 people with learning disabilities, for male and female residents. The home has two flights of stairs, both going onto the 1st floor. This would make accommodating someone with mobility problems difficult, although there are some bedrooms and a bathroom and toilets downstairs. There is one double room at the home. There is a separate dining area as well as a seating area in the kitchen. The home has two dogs and a cat. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a three hour period. During this time the inspector spoke with the registered manager and staff. Residents were spoken to on their return from the day centre. Records were also inspected including service users files. What the service does well: What has improved since the last inspection? What they could do better: Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 6 Their were minor issues identified within the medication administration records, and also minor issues concerning recording of meals provided. Although all complaints were taken seriously, informal complaints were not always recorded in the complaint record. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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 the following standard(s): 5 Residents did not have all the information required concerning the terms and conditions with the home. EVIDENCE: Each service user had a contract between themselves and Social Services. There were no self-funding residents at the time of the inspection. Although there was some specific information in the statement of purpose and service user guide, there was not a specific terms and conditions document between the home and each resident. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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 the following standard(s): 7 Residents were supported to make decisions about their own lives. EVIDENCE: Staff respected resident rights to make decisions about their own lives. Some rights had been limited in the residents’ best interests. An example was a resident that had lost four keys to the main door of the home. It had been decided by the manager that another key would not be given. The issues concerning these were recorded and took into account the health and safety of other residents. One resident wanted to use public transport to visit their family. As a result of a risk assessment it was agreed that support and training was required before the resident could go alone. Residents chose where to go on holiday and whether they wish to go abroad or in the UK. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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 the following standard(s): 12, 16, 17. Residents were encouraged to take part in appropriate activities. The daily routines and house rules promote independence, choice and freedom of movement. Residents were offered a nutritious diet and enjoyed their meal times. EVIDENCE: Although there were no residents that had jobs or voluntary work, residents were encouraged to be involved in fulfilling activities. One resident used to attend Red Cross, but decided to stop as they were becoming too tired at the end of the day. Three residents attended a literacy group. One resident had the choice to attend a literacy group in the day, or the day centre, and they had chosen the day centre. Two residents enjoyed walking the dogs that were living at the home. One resident was involved in conservation through the day centre, and another undertook voluntary work at a car wash, also run by the day centre. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 11 There was some routines within the home that seemed to be enjoyed by residents. An example was that residents enjoyed eating together at set times after day centre. It was stated that staff always knock and wait before entering bedrooms. Residents had been consulted concerning bedroom keys, and no one wanted a key, although one resident leaves their key in the bedroom lock. It was recorded in individuals care plans whether residents had agreed to staff entering their rooms when they were not there. The manager confirmed that mail was given to residents unopened, and support was given with mail when required. Some residents had a key to the front door of the home. Residents had unrestricted access within the home apart from the staff bedroom and a small office that was kept locked. The care plans stated some preferences concerning housekeeping tasks. Residents took turns to plan the weekly menu. There was a choice at breakfast and a cooked breakfast was an option. Any changes to the menu were recorded, but this record did not include the reason for the change. Records were not made when an individual had an alternative from the planned menu. Each resident had a nutritional assessment, and weight was recorded and monitored. One resident required a soft diet. A healthy diet including high-fibre and fresh fruit was encouraged. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 20 Residents were protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The registered manager had recently revised medication policy. The pharmacist visited annually to undertake an audit. Staff had undertaken safe handling of medicines course at college, but as this was not accredited they were planning to undertake further training via the pharmacist. Medication was safely stored. There was a photo of each resident within their medication records. Some residents were self-medicating creams, but this was not recorded as such. There was a recording system for returning medication. Medication administration records showed that staff on occasions had not signed that they had administered medication. This omission was concerning creams. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 22 Residents and families concerns were listened to and acted on. EVIDENCE: There was a written complaints procedure. This was also included in a video about the service. It was stated that there had been no complaints since the last inspection. However from discussion with the manager there had been some complaints, even though they may not have been upheld. Some complaints were from a resident concerning another resident. These have not been recorded in the complaints record. It was clear however that any issues highlighted by either residents or families were taken seriously and resolved quickly. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 24 Residents live in a homely, comfortable and safe environment. EVIDENCE: The premises were well maintained and met residents’ individual and collective needs. The registered person and deputy manager dealt with maintenance and repair quickly. The home was not fully accessible for any residents with significant mobility difficulties as there were two floors to the home. There were however four bedrooms on the ground floor, with a ramp and grab rails when required. There was a small kitchen step, however all residents were able to negotiate this step. The registered providers had planned to take out the chimney breast within one bedroom in order to make the room larger. This was in agreement with the resident, who had chosen their wallpaper and laminate flooring. There will also new cupboards planned in the kitchen. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Residents’ needs were met by experienced staff. EVIDENCE: The manager stated that all staff had undertaken moving and handling, first aid, food hygiene and adult protection training. Fire training was planned later in November. Two staff had obtained NVQ 2 Care, and one of the staff had started NVQ 3 Care. One worker was an NVQ assessor. There were six care staff working at the home. The deputy manager had obtained a B.T.E.C. Health and Social Care qualification. Staff had also undertaken training concerning downs syndrome and safe eating in order to support specific residents. As stated previously additional medication training was planned. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42. Residents were consulted and fully involved concerning the service provided. The health, safety and welfare of staff and service users were promoted and protected. EVIDENCE: There were regular residents meetings that were enjoyed by the residents. The minutes were inspected and showed that residents were consulted about a wide variety of issues regarding the home or issues that were of concern to them. Views of relatives were sought. Some relatives were frustrated having to regularly give their views when they were very satisfied, therefore only two questionnaires were returned. Examples of comments on these questionnaires were, staff are always very obliging and seemed to enjoy their work and, as parents we couldnt be happier with the staff and the home. Another comment received was, the home always has a lovely atmosphere to it and we are always made welcome. It was evident from discussions with residents that they were used to making suggestions that were met where possible. An example was one resident requesting that the home provided beer on bonfire Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 17 night with their food, which was provided. There was a high level of satisfaction amongst residents. One resident told the inspector that, Id like to live here always. As the registered provider was no longer the manager, the registered provider now needed to write a monthly report concerning the conduct of the home. The home had recently become a Limited Company. The registered providers had not appreciated that this meant that the service needed to apply to CSCI to become a registered organisation. There was safe storage of hazardous substances in the laundry and a locked cupboard in the cellar. It was stated that servicing of boilers and the central heating system had taken place. Fire safety equipment was serviced and the fire alarm was regularly tested. There were window restrictors on every window, and the premises were secure. Relevant training and guidance had been provided for staff. A distance learning course concerning infection control was planned. There were written risk assessments concerning some but not all safe working practice topics. There was a system for recording accidents. Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Vicarage (The) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X 2 DS0000020065.V265665.R01.S.doc Version 5.0 Page 19 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 YA5 Regulation 5b Requirement There must be a statement of terms and conditions between the home and the service user, which has been signed by the registered manager and service user where possible, There must be no omissions in the medication administration records. There must either be staff initials or an appropriate code. Where the medication has been handed to a service user for selfmedication, there should be a signature and date of the medication given and where appropriate the signature of the resident that they have received this medication. All complaints including informal complaints must be recorded in the complaints record. The registered provider must complete a written report on a monthly basis concerning the conduct of the home. This report should include evidence of interviews with residents and staff and inspection of the premises and records. DS0000020065.V265665.R01.S.doc Timescale for action 30/01/06 2 YA20 13(2) 08/11/05 3 YA20 13(2) 08/11/05 4 5 YA22 YA39 22 26 08/11/05 30/12/05 Old Vicarage (The) Version 5.0 Page 20 5 YA43 CSA 2000 The registered provider must make an application to CSCI in order to become a registered organisation. 15/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA17 YA17 YA42 YA42 Good Practice Recommendations When an alternative to the planned menu has been provided for residents, the reason for this alteration should be recorded. When an individual has an alternative meal to the main menu, the meal provided for this individual should be recorded. There should be written risk assessments concerning all safe working practice topics. See Standard 42.6. Staff should receive training in infection control. (This was only made a recommendation as there were no concerns regarding risk of infection) Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Vicarage (The) DS0000020065.V265665.R01.S.doc Version 5.0 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!