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Inspection on 05/07/06 for The Old Vicarage Care Home

Also see our care home review for The Old Vicarage Care Home for more information

This inspection was carried out on 5th July 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All new residents are assessed prior to admission and are provided with information about the home. A care plan is prepared detailing how each admission is to be managed. Each resident has a well completed care plan ensuring that staff are aware of residents needs and how these are to be met. Residents and relatives are involved in the review of care plans. There are good arrangements in place to ensure that the healthcare needs of residents are met. There is a varied activities programme providing residents with opportunities to take part in a variety of games, sing a longs or trips out of the home. There is a monthly communion service held in the home. A full and varied menu is provided and residents are provided with a choice of meal. The home is well laid out and suitable for use as a residential home. The home was clean and well maintained making a pleasant environment. There is an efficient laundry service to launder residents clothing. Then home provides sufficient staff on each shift to meet the needs of the residents. The home is well managed with the manager continuing to undergo training for her own development so she can ensure best practices are followed in the home.

What has improved since the last inspection?

Staff are required to read one of the home`s policies and procedures each moth and sign to say they have understood this. This is to ensure that staff are aware of how the home is expected to run to best meet residents needs.

What the care home could do better:

The staff training records must b kept up to date so that it can be identified whether any staff have not completed the required training or are due for any updates to ensure they are able to meet residents needs appropriately. All staff must receive training on working with people with dementia so they have the skills to care for these residents within the home. The home has a complaints procedure but no all complaints made are recorded as required to ensure that any concerns residents have are appropriately dealt with.

CARE HOMES FOR OLDER PEOPLE The Old Vicarage Care Home Newcastle Avenue Worksop Nottinghamshire S80 1NJ Lead Inspector Stephen Benson Key Unannounced Inspection 5th July 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.V302224.R01.S.doc Version 5.2 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.V302224.R01.S.doc Version 5.2 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 None Southern Cross Care Homes No 2 Limited Susan Jayne Wright Care Home 38 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (26) of places The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within categories (OP) 26 beds or DE over 55 years of age (12) beds 11th January 2006 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, 12 of whom have dementia. 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 Worksop 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 manager said on 05/07/06 that the fees for the service range from £277 £450 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2006 by The Commission for Social Care Inspection. The inspection lasted for 5 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 and relatives 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: All new residents are assessed prior to admission and are provided with information about the home. A care plan is prepared detailing how each admission is to be managed. Each resident has a well completed care plan ensuring that staff are aware of residents needs and how these are to be met. Residents and relatives are involved in the review of care plans. There are good arrangements in place to ensure that the healthcare needs of residents are met. There is a varied activities programme providing residents with opportunities to take part in a variety of games, sing a longs or trips out of the home. There is a monthly communion service held in the home. A full and varied menu is provided and residents are provided with a choice of meal. The home is well laid out and suitable for use as a residential home. The home was clean and well maintained making a pleasant environment. There is an efficient laundry service to launder residents clothing. Then home provides sufficient staff on each shift to meet the needs of the residents. The home is well managed with the manager continuing to undergo training for her own development so she can ensure best practices are followed in the home. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V302224.R01.S.doc Version 5.2 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.V302224.R01.S.doc Version 5.2 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 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. New residents are assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: Care files seen contained assessments of residents needs. The manager said that either she or the deputy will go out to assess prospective new residents and will complete a pre admission form. Information about the home, including the Statement of Purpose and Service User Guide are sent to the prospective resident. When an enquiry was made from oversees information about the home was emailed to the person making the enquiry. The manager said if it is felt that the prospective residents needs can be met within the home a fee is worked out on the basis of the individual’s needs and arrangements are then made for the person to visit the home. A care plan is prepared for the admission of a new resident. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 9 Staff said that they are given information about any new resident at handover and are encouraged to read the care plan. Residents spoken with were not able to comment on what happened prior to moving to the home. There is no arrangement made for the home to provide an intermediate care service. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social care needs are set out in an individual plan of care. Residents’ health care needs are fully met. Residents are protected by the homes procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy upheld and their wishes are acted upon. EVIDENCE: Care plans seen were well completed giving clear guidance as to how each residents needs are to be met. The manager and deputy are responsible for completing plans and the manager said that the views of the resident, where able, relatives and staff are sought when preparing plans. Letters were seen inviting relatives to attend care plan reviews and asking them to arrange to discuss their relative’s care plan with the manager. The manager said that senior staff have started evaluating care plans and a new key worker system The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 11 has been introduced. Staff said that they regularly refer to care plans and find these useful. Residents said that they had discussed their care plan in a meeting. There are visits to the home by the chiropodist and optician who see residents on a regular basis. The manager said there is not a dental service available for routine check ups, but a service can be accessed if needed. The manager said that two residents have recently had new dentures and a record of this was seen in a care plan. A resident said that she had recently had some new dentures. There are visits from the district nurse and doctor as required and staff said that if someone is unwell a doctor is called. Appropriate equipment was seen to help prevent pressure sores and a resident said that she has to use a special cushion to protect her. Appropriate lifting practices were observed using a hoist. Senior staff are responsible for administering medicines and they must have completed a safe handling of medicines course before they are allowed to do so. The manager showed a file detailing staff competencies for administering medication. Medicine Administration Records were seen and these were fully completed, except one recently admitted resident did not have a Medicine Administration Record completed by the pharmacist so this had been handwrite in the home. This had not been signed by the person completing it or checked by another member of staff. Residents said that staff bought them their medication and watched them take it. Staff described good practices to promote the privacy and dignity of residents when providing personal care. A resident said that she did not like being assisted by a male carer and the manger said that this had only recently been mentioned and arrangements have been made for only female staff to assist this resident. Residents appeared well dressed and clean although one resident was seen needing some adjustment to his clothing, which was not responded to by staff at the time. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 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, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations. Residents maintain contact with family and friends. Residents are helped to exercise control over their lives. Residents receive a wholesome and balanced diet. EVIDENCE: The home employs an activities coordinator for 15 hours per week who organises in house activities and trips out. One of the kitchen staff also assists with activities when the coordinator is not on duty. There was a varied range of equipment seen including skittles, darts, board games and videos. There were posters advertising a Spanish evening, a clothes party and a summer fayre. There were leaflets on the notice board for local events and the coordinator said arrangements would be made to take any residents who expressed an interest in going to these. There was also a notice advertising a regular communion service. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 13 Staff were seen singing happy birthday to a resident and telling her the arrangements for the day. Residents said they enjoy activities such as dominoes and flower arranging. A record is made of all activities each resident participates in and these showed that the majority of residents participate in activities on a regular basis. There are some residents who prefer not to join in any activity and some residents require a more individual programme. The manager is looking to increase the amount of hours allocated to activities to enable greater individual attention for those residents who require that. No visitors were spoken with during the inspection but residents talked about receiving visitors and said that they can visit at any time. An entry is made in the daily records when a resident has a visitor. The manager said that opportunities for residents to make choices are promoted and this included all aspects of daily living. Staff said that they always ask residents what they want to want and a resident said she always decides what she is going to put on. Residents also said that they sometimes have a bath or shower. A resident had requested to have her bedroom window open beyond the safety restriction and a risk assessment was undertaken which enabled this to happen. The kitchen was well organised and there is a planned menu. The cook said that this is not currently being stuck to due to the hot weather and residents are wanting lighter meals. A choice of meals is provided and further alternatives are available if wanted. There are some residents who have special diets and the cook said that she is able to cater for these. A resident said that she requires a special diet, which is provided. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to. Residents are protected from abuse. EVIDENCE: The home has a complaints procedure and there is a log to record any complaints in. The information in the log is brief, however the manager found a further form on Southern Cross intranet that should be completed with the log that she was unaware of. Staff said that they pass any concerns or complaints onto the senior on duty. There was a record in a care plan of a meeting held with a resident and her relative to resolve some difficulties raised. This was a positive response to a resident who frequently made complaints, which were unsubstantiated. The complaints raised had not however been recorded in the complaints log and the manager must ensure that all complaints are recorded. One resident said that she often makes complaints and had discussed these with the manager. The home has policies for protecting adults and whistelblowing which staff are expected to sign to say they have read and understood. Not all staff have signed these and the manager said she will ensure that this is done. There have not been any reported incidents of abuse. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 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 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. 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. A resident said that she can reach all areas of the home in her wheelchair. Some of the entrances to the home have a ramped access. The laundry is well organised and residents were pleased with this service. There are policies and procedures for infection control. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The rota shows that there are five care staff on duty in the mornings, four in he afternoon and three at night. There is always a senior member of staff on duty and there is a good back up of ancillary and administrative support. The layout of the building means that staff can be some distance from each other and the registered person is reminded that they must be satisfied that the home is adequately staffed at all times. The manager said that all staff are signed up to undertake National Vocational Qualification level 2 and have an assessment day booked shortly. Staff said that they are waiting for some tests to see if they can undertaker the course. A selection of staff files were seen and these contained the required information. There is an electronic system for recording all staff training, however this was not fully up to date and it was not possible to see which staff had completed all the required training. Senior staff have undergone training The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 17 in dementia care, but other care staff have not. All care staff work on the dementia unit so they must be provided with this training. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 18 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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable manager employed to run the home. Residents have opportunities to express their views on how the home is run. Residents’ financial interests are safeguarded. The health, safety and welfare of residents are protected. EVIDENCE: The manager has a number of years experience working in the home and has relevant qualifications. The manager was observed providing staff withy guidance over practice and there were entries seen in staff files where staff The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 19 conduct was appropriately addressed. The manager demonstrated a good understanding of her role and showed herself to be an efficient manager. The manager undertakes routine audits of services provided and prepares a report form these. The manager said that residents and relatives can discuss anything they want to with her at anytime and she holds a weekly surgery when residents and relatives can come to discus any matter they wish with her, although this is not taken advantage of. There were resident/relative survey forms sent out in April 2006 and a number of these have been returned. They were mainly very complimentary about the service and where issues were raised the manager had already addressed these, for example some comments said that they did not know who the keyworker was and a list has been produced identifying each residents keyworker. Where required the home will help residents manage their personal allowances. An electronic record is made of each transaction and this is audited by an external manager. There as been a recent break in to the home and the safe was stolen. There has been increased security added and residents money stolen has been reclaimed on the home’s insurance. All required health and safety checks and tests are carried out at the required frequency and there were notices informing staff of health and safety training. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 20 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 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 2 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 21 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 OP30 Regulation 18 Requirement The registered person must ensure that staff training records are kept up to date and all care staff must be provided with training on dementia care. The registered person must ensure that all complaints made by residents are recorded Timescale for action 01/11/06 2 OP16 22 01/08/06 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 Refer to Standard OP8 Good Practice Recommendations The registered person should ensure that where staff write out a residents Medicine Administration record this is signed by the staff doing so and witnessed to be correct. The Old Vicarage Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 22 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 © 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 Care Home DS0000039355.V302224.R01.S.doc Version 5.2 Page 23 - 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. 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