CARE HOMES FOR OLDER PEOPLE
Old Vicarage (The) St Mary`s Street Chippenham Wiltshire SN15 3JW Lead Inspector
Malcolm Kippax Unannounced Inspection 10:15 1st March 2006 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 Old Vicarage (The) DS0000059130.V280784.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. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Old Vicarage (The) Address St Mary`s Street Chippenham Wiltshire SN15 3JW 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) 01249 653838 01249 651173 The Old Vicarage (Chippenham) Ltd Miss Cheryl Williams Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: The Old Vicarage is a private care home for up to 20 older people. The home is owned and run by Mr and Mrs Williams and Cheryl Williams, who have formed a limited company. The Old Vicarage is a period property located opposite the Church and within walking distance of local shops and amenities. The accommodation is spacious and well decorated. Bedrooms are mostly large and furnished as bed sitting rooms, with en-suite areas. The communal areas include a large lounge and a formal style dining room. There is a large garden, leading down to the river, with patio areas. Cheryl Williams is the registered manager and works alongside a care manager and a team of permanent staff members. A key worker system is in operation, with each staff member providing personal care and carrying out cleaning tasks in the home. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place between 10.15 am and 3.00 pm. It focussed on a number of key standards that were not looked at during the previous inspection. Service users and staff members were met with throughout the visit. There were individual meetings with four service users in their own rooms. The registered manager and the care manager were both available and assisted during the inspection. There was a partial tour of the accommodation. Records and procedures were looked at, including quality assurance, health & safety and fire log book. A pharmacist inspector from the Commission looked at the medication arrangements. Comment cards had been sent to the home prior to the inspection to be given out to relatives and visitors. Seventeen have been returned to the Commission (ten from service users and seven from relatives/ visitors). What the service does well: What has improved since the last inspection?
Service users benefit from the training that staff members receive. This has continued since the last inspection and the manager said that she had now completed the registered managers award. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 6 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. Old Vicarage (The) DS0000059130.V280784.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 Old Vicarage (The) DS0000059130.V280784.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): These standards were not looked at on this occasion. (Standard 3 was met at the last inspection. Standard 6 did not apply). EVIDENCE: Old Vicarage (The) DS0000059130.V280784.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): 9 Residents are protected by the home’s procedures whether they have medicines administered to them or chose to retain control of their own medication. (Standards 7, 8 and 10 were met at the last inspection). EVIDENCE: Medication is stored securely and all appropriate records maintained. Administration is individual and the record is signed at the time of administration. Some residents retain responsibility for taking their own medication. This process is thoroughly risk assessed and regularly reviewed. A resident described the routine of checking and ordering the medicines that the staff carry out. All staff who administer medication undergo in-house training and reviews. The home has signed up for further training courses and are awaiting start dates. A medication policy and administration procedure is made available to all staff. Old Vicarage (The) DS0000059130.V280784.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): 14 Service users have the independence that they want and can exercise choice and control within the home (Standards 12 and 13 were met at the last inspection. Standard 15 was exceeded). EVIDENCE: Each of the service users met with felt that they were able to exercise a good degree of choice and independence within their daily routines. The bedrooms seen had a homely and individual appearance. The service users had brought a range of personal possessions and items of furniture with them when moving into the home. One service user met with said that she received regular support with reading her letters. The service user said that she used to enjoy reading but this was no longer possible for her. The use of ‘talking books’ was discussed. The manager has had experience of providing these for service users and said that she will talk about this with the service user in question. During the morning, some service users had chosen to attend a Communion service in the home. There was a good range of information in the front hall, which was readily accessible to service users and visitors. This included the home’s Statement of
Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 11 Purpose, the last inspection report, and leaflets about local services for older people, including advocacy. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 12 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): These standards were not looked at on this occasion. (Standards 16 and 18 were met at the last inspection). EVIDENCE: Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 13 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): 26 Service users live in clean and tidy surroundings (Standard 19 was met at the last inspection). EVIDENCE: Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 14 The areas of the home seen during the inspection were clean and tidy. Service users who were asked said that they are satisfied with the standard of cleaning within their own rooms. Rooms were being cleaned during the morning and a carer was met with in one service user’s room. The carer said that she had a dual role, as a ‘key carer’, which involved caring for a number of service users and also the cleaning of their rooms. The carer said that another person did the cleaning in the bathrooms. The carer adopted a flexible approach when the inspector was talking with one service user and was able to return to the bedroom for further cleaning after the meeting. An up to date cleaning checklist was seen in the service user’s room. The communal areas seen were well furnished and decorated, in a coordinated style. There were no unpleasant odours. An environmental health officer had last visited the home in December 2004. The report was seen and there were no requirements identified at the time. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 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): These standards were not looked at on this occasion. (Standards 27 and 30 were met at the last inspection. Standard 28 was exceeded and standard 29 was almost met). EVIDENCE: Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 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): 33, 35, and 38 There is a comprehensive system for quality assurance, although the outcomes and completion of this are not fully documented. Service users manage their own financial affairs with the support of people outside the home. There are systems in place for the monitoring of health & safety. (Standard 31 was met at the last inspection). EVIDENCE: The home’s ‘Statement of Purpose’ included comments about the arrangements made for quality assurance. This referred to a ‘Quality Management System’ and information about this was kept in a separate quality manual file.
Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 17 The quality manual file consisted of guidance about the operation of the system, which includes the monitoring of satisfaction surveys, an annual review of procedures and a management review of the system, with evidence of ‘improved services to residents’. There were insufficient records to provide evidence about the current implementation of the system and how it contributes to an improvement or annual development type plan for the home. The home’s Statement of Purpose included a copy of a business plan dated April 2003. Since the inspection, the manager has sent a more recent business plan to the Commission, together with further documentation about the home’s quality assurance system. Questionnaires about the service users’ satisfaction have previously been sent out to service users, although the manager said that these had produced little feedback. The manager reported that the home has no involvement with the service users’ financial affairs, as the service users handle these personally or with the support of their families. There is some occasional billing of relatives, which has been agreed for certain expenditure. The home’s fire log book was up to date. A fire risk assessment, dated 18.01.06 had been written. This described the arrangements in place, but did not include an ‘outcome’ section, stating whether the level of risk was acceptable, or whether additional safety measures are needed. The manager described various ways in which health & safety is monitored and actioned in the home. The records seen included a Health & Safety Inspection checklist. This covers a wide range of facilities, maintenance and safety aspects within the home, but did not include the grounds and outdoor health & safety. The checklist had been ticked up to March 2006. The home’s fire log book was up to date. A fire risk assessment, dated 18.01.06 had been written. This described the arrangements in place, but did not include an ‘outcome’ section, stating whether the level of risk was acceptable, or whether additional safety measures are needed. There was also a general risk assessment and one for the building. Servicing arrangements are in place for different items of equipment and facilities in the home, such as the passenger lift and assisted bath. The certificate of electrical installation was not available and the manager agreed to forward a copy of this to the inspector. Some in-house checks are made, including the call alarm system and water temperatures. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 18 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 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 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 3 X 3 X X 3 Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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. 5. Refer to Standard OP33 OP33 OP38 OP38 OP38 Good Practice Recommendations That timescales are identified within the system of quality assurance in order to show when the different components are to be implemented and the date for their completion. That the policy on quality assurance is developed to show how the system contributes to the completion of an annual development or improvement type plan for the home. That an ‘outcome’ section is included on the fire risk assessment form. That a comment, rather than a tick, is recorded on the Health & Safety Inspection checklist. That the grounds and outdoor facilities are included in the Health & Safety Inspection checklist. Old Vicarage (The) DS0000059130.V280784.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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