This inspection was carried out on 26th September 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.
CARE HOMES FOR OLDER PEOPLE
The Old Vicarage Care Home Newcastle Avenue Worksop Nottinghamshire S80 1NJ Lead Inspector
Stephen Benson Unannounced Inspection 26th September 2005 09:00 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 Care Home DS0000039355.V253565.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 Care Home DS0000039355.V253565.R01.S.doc Version 5.0 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.V253565.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 2/11/04 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.V253565.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the first of two unannounced inspections to be carried out between April 2005 and March 2006. The inspection lasted for 3 ½ hours and 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 and care practices were observed. A visiting hairdresser was also spoken with. No relatives or visiting healthcare professionals were spoken with. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection?
The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 6 No requirements or recommendations were set at the last inspection as all standards inspected were met or exceeded. Some building work is in the process of being carried out to adapt the accommodation to be able to have a separate area of the home to accommodate people with dementia. 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 Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Residents health, personal and social needs are clearly set out in care plans and met. The recording of drug administration needs to be improved. EVIDENCE: Care plans were well organised and easy to follow. They included assessments, risk assessments and plans of care. Plans are regularly reviewed and evaluated and examples were seen where plans were updated. There was also evidence seen of resident involvement in their plan. The language used in plans promoted choice and independence for residents. Residents spoken with were aware of their plans and one recently admitted resident said that staff had discussed her plan with her. As there has been a recent change of ownership of the home care plans are having to be rewritten onto new paperwork, which show the new company logo. A close watch is kept on residents well being through regular assessments and monitoring. A record is made in the care plan of all healthcare visits. One resident was seen returning from the dentist and an appointment was made for another. An optician carries out eye tests in the home. Residents said that they were happy with then healthcare they receive and can always have a doctor to see them if they request.
The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 10 There is a designated treatment room where all medicines are stored. The storage of medicines was well organised and complies with the relevant guidance and the administration of medicines was mostly well recorded, however there were some errors seen in both the Medicine Administration Records (MAR) and the controlled drug register. These included no record made of whether some medicines had been administered as there were gaps on the MAR sheets, errors in counting controlled drugs and some entries in the controlled drug register only had one signature rather than the required two. Staff spoken with were aware of the correct procedures to follow. The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 11 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, 13, 14 and 15 Residents have opportunities for a lifestyle that suits them and can keep in contact with families and friends. Residents are able to make choices that effect them. A balanced and wholesome diet is provided. EVIDENCE: Residents social needs are included in care plans and there is an activities coordinator who organises daily activities Monday to Friday. Details of activities on offer for the week are displayed on a notice board in the entrance hall and there are framed photographs of previous activities displayed around the home. A monthly church service is held. Residents were seen making use of differing areas of the home and gardens and some were seen discussing whether there was anything they wanted to watch on television. Residents said they are told when activities are on and they can choose if they want to take part or not. Residents said they enjoyed singsongs and liked the visiting organist. Visitors are welcome at any time and can either visit residents in their room or use one of the communal areas. The visiting hairdresser has been moved from her previous base, due to the current building work, to an upstairs bathroom. This does not provide sufficient space and residents were being left in a corridor. The manager said that residents are provided with opportunities for choice where possible and staff were observed offering choices to residents about where they wanted to sit, what they would like to drink and whether to have
The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 12 lunch in their room or in the dining room. Staff spoken with demonstrated an understanding of how to promote choice. The manager asked permission from those residents selected for case tracking for this inspection to show their care plans. Residents said they make choices all the time and staff help them to do so. The home operates to a 4 week menu which is changed with the seasons. The cook said that she is preparing to compile new menu and does so in conjunction with the residents. Food provided is usually home made and residents said they were very happy with the food they get and that they have plenty top eat. The main meal is eaten at lunchtime and although there is not a choice of main meal alternatives are available and special diets catered for. Any particular wishes or preferences can be accommodated, an example being a resident recently asked for sardines on toast and these were provided. Lunch is served by the cook in the dining room so she can receive any feedback on meals directly from the residents. The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 13 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): None EVIDENCE: The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 14 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 and 26 The home is safe and well maintained as well as having considerable character. There is a high standard of cleanliness and hygiene and an efficient laundry service. EVIDENCE: The home is an older building, which has considerable charm and character that has been maintained whilst adapting it to meet the needs of older people. There are plenty of communal rooms to use including lounges on both the ground and first floor. It has been tastefully decorated and furnished in keeping with the surroundings. The home is kept clean, fresh and well maintained. Any repairs are reported to the handyman who promptly attends to them. Residents said it was a lovely place and praised the cleanliness. The laundry is well organised and residents were pleased with this service where clothes are usually returned clean and ironed the same day. There are policies and procedures for infection control and staff were seen using a gel wash. The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 15 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): None EVIDENCE: The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 16 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): 38 The health and safety of residents and staff are promoted and protected. EVIDENCE: Staff were seen observing safe working practices and a record is made of all mandatory training. There were information notices of any dangers and residents said they have heard the fire alarm being tested. The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 4 X X X X X X 4 STAFFING Standard No Score 27 X 28 X 29 X 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 18 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 9 Regulation 13 Requirement Ensure all drug administration records are correctly completed Timescale for action 26/09/05 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 12 Good Practice Recommendations Identify a more appropriate area for hairdressing The Old Vicarage Care Home DS0000039355.V253565.R01.S.doc Version 5.0 Page 19 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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