This inspection was carried out on 11th January 2006.
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.
CARE HOMES FOR OLDER PEOPLE
The Old Vicarage Care Home Newcastle Avenue Worksop Nottinghamshire S80 1NJ Lead Inspector
Stephen Benson Unannounced Inspection 11th January 2006 09:30 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 Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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 Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Old Vicarage Care Home Address Newcastle Avenue Worksop Nottinghamshire S80 1NJ 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) 01909 475521 01909 483316 Southern Cross Care Homes No 2 Limited Susan Jayne Wright Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection Brief Description of the Service: The Old Vicarage is a care home providing personal care and accommodation for 39 older people. The home provides short and long term care. The home is owned by Southern Cross Care Homes No 2, which is a limited company. The home is located in a residential; area of Retford and is a former vicarage. 39 of the home’s bedrooms are single, and 23 of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there are 2 passenger lifts. The home has gardens that are well maintained and easily accessible. There is ample car parking available. Since the last inspection the home has carried out some physical alterations to the building in order to alter their registration to include people with dementia, which is currently being considered by the Commission for Social Care Inspection. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 hours and the inspection focussed on key standards not inspected at the last visit. The main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty, relatives and care practices were observed. The premises were inspected as part of the process to vary the home’s registration to include dementia. What the service does well: What has improved since the last inspection? What they could do better:
Although residents felt that staff responded promptly and appropriately to any complaints they were unclear on the complaints procedure. They were also The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 6 unaware of the procedures that should be followed in the event of any allegation of abuse or the policy on whistleblowing. 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 Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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 Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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): 3 New residents are assessed prior to admission to ensure that their needs can be met. EVIDENCE: There is a system in place to assess all new residents prior to admission to ensure their needs can be met. Files seen showed that these are completed prior to the admission of a new resident. Additionally where residents are assessed by Social Services and or the NHS copies of these assessments are obtained. Staff spoken with said that copies of the assessments are made available to them prior to the resident moving in and also that information about the needs of new residents is passed over in handover. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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): 10 Residents are treated with respect and their right to privacy upheld. EVIDENCE: Staff described good practices in promoting the privacy and dignity of residents. Staff also said that through working with different colleagues they are able to know how they work and this helps when inducting new staff. Residents said that they were very much respected by staff and where personal care was needed staff provide this sensitively. One resident who requires a high level of support said that she felt safe with whoever was assisting her. Care practices seen confirmed this to be the case. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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): None EVIDENCE: The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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 and 18 Residents are confident that staff will respond to their complaints and feel safe. EVIDENCE: The home has a complaints procedure and complaints book in place. Residents said that staff were very good if they tell them something is not right, and they sort it out straight away. Staff described responding to issues raised by residents, however they were unclear on the Complaints Procedure. Staff were also unaware of the Adult Protection procedures or the homes Whistleblowing policy and all these should be explained to them. Residents said they were very well treated by staff and relatives said that they thought all staff were very caring. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 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): None EVIDENCE: The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 13 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, 28, 29 and 30 The home has sufficient and suitably trained staff on duty at all times. EVIDENCE: The rota plans for there to be 5 care staff on the early and 4 on then late shifts. In addition there is a full time manager, administrative, catering, domestic maintenance, laundry support. The home also employs an activities coordinator. Residents said that the home is usually well staffed but when they have had to work short because someone has phoned in sick they do a marvellous job getting everything done. Staff receive regular training including undertaking NVQ’s. One recently appointed member of staff said she would like to take one and another said she had finished level 2 and was halfway through level 3. Residents said that they felt that staff were well trained to carry out their work. The correct recruitment procedures are followed in the appointment of new staff. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 14 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 and 35 The home is well managed and residents are able to express their views. EVIDENCE: The manager has worked in the home for a number of years and was highly praised by residents and staff. The manager has relevant qualifications and has a clear understanding of her role. Where the home looks after residents personal allowances a record is kept of every transaction, which is signed and witnessed by 2 staff. Residents felt that their views are listened to and there are quality assurance systems in place. The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 15 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? No 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 16 and 18 Regulation 18 Requirement Ensure that staff are familiar with the homes complaints and whistleblowing policies and the Adult Protection Procedures. Timescale for action 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Vicarage Care Home DS0000039355.V277265.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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