Inspection on 03/10/05 for The Old Vicarage, Chippenham

This inspection was carried out on 3rd October 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.

Other inspections for this house

The Old Vicarage, Chippenham 05/06/07

The Old Vicarage, Chippenham 01/03/06

The Old Vicarage, Chippenham 02/03/05

The Old Vicarage, Chippenham 14/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage (The) St Mary`s Street Chippenham Wiltshire SN15 3JW Lead Inspector Malcolm Kippax Unannounced Inspection 09:20 3 October 2005 rd 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.V253445.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. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 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.V253445.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 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.V253445.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection started at 9.20 am and lasted for 6½ hours. Service users were mainly met with in their own rooms, but also in the lounge and in the dining room. This included service users who had moved into the Old Vicarage since the previous inspection and others who have lived at the home for a number of years. There were individual meetings with two staff members and with a service user’s relative who was visiting at the time. The manager spoke about some recent developments affecting the home. Records, including care plans, assessments, staff recruitment, training and menus were looked at. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to ensure, for the protection of service users, that all necessary checks are made before a staff member starts working in the home. The care records showed that significant events affecting the service users are being reported. However, it is recommended that health appointments and any follow-up action are clearly highlighted within the records. This will enable changes in health care to be more easily identified and monitored. A separate form for the recording of health related matters could be beneficial and used to achieve the same result. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 6 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.V253445.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 Old Vicarage (The) DS0000059130.V253445.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): 3 New service users benefit from the admission arrangements that are in place. EVIDENCE: The home uses an ‘Admissions Checklist’, which helps ensure that all aspects of a new admission are dealt with in a planned way. The manager said that three new service users had moved into the home since the last inspection. An individual file is set up when a new service user moves into the home. One of the new service user’s files was looked at. This included a copy of the preadmission assessment that had been carried out by the manager, as well as other information that would be useful for staff to know. A new service user said that she was settling in and named the keyworker on the staff team who mainly helped her with room cleaning, as well as with personal care. She was familiar with other staff members, but suggested that personal badges would help a new service user to recall their names. The two staff members met with were both in the role of keyworker. Each was knowledgeable about their role, which included helping new service users to settle in. Old Vicarage (The) DS0000059130.V253445.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 10 Information about the service users’ needs and individual routines is clearly set out and recorded. Service users receive support with their health care and feel that they are treated with respect in the home. EVIDENCE: The home’s pre-admission assessment is used as the starting point for a written care plan. Two types of care plan were seen. The more detailed of these was contained in the service users’ individual files. The examples looked at included relevant details and were being updated using a monthly review form. Service users had signed the care plans. The service users met with were aware of another care plan that is kept in their rooms, often out of sight in the en-suite area. This is primarily for the use of staff and shows the care and support that the service user needs on a daily basis. Service users were happy for these plans to be looked at although comments were made that it was not something they took a particular interest in. The plans are a single sheet and serve as a useful reminder for staff about the support that is needed. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 10 The service users’ records included reports that are written approximately weekly, or more often if needed, about significant events and changes affecting service users. Contact with health care professionals is recorded alongside other matters such as social events and general observations. The highlighting within the records of health appointments and follow-up action would help in the monitoring of health and identifying when changes have occurred. The manager said that one service user was having visits from the district nurse and that a form of short term care plan, with guidance for staff had been produced in connection with this. Each service user has the privacy of their own room. Comments from service users indicated their satisfaction with how they are treated. One person commented that ‘we are all on Christian names here’. Staff members were observed to knock on bedroom doors before entering. Old Vicarage (The) DS0000059130.V253445.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 and 15 The lifestyle at the Old Vicarage suits service users. The home’s location is convenient for service users, who have maintained relationships and contacts that are important to them. Service users are happy with the meal arrangements and meals are freshly prepared in the home. EVIDENCE: Some service users were using the lounge, where a session organised by the University of the Third Age was held during the morning. This is one of some regular activities that are held in the home, including gentle exercise sessions, musical entertainments and reminiscence groups. Service users are supported with maintaining Church contacts and one service user met with said that a priest from the Catholic Church visited weekly. Holy Communion takes place on a four weekly cycle. The main care plans include details of the service users’ wishes in this area and their social interests. The majority of service users were spending time in their own rooms, which are mostly furnished as bedsitting room type accommodation. Several service users met with had their own telephones, facilities for making hot drinks in their rooms and had their own newspapers delivered. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 12 The manager said that four people were able to go out by themselves. One service met with described the home as ‘free and easy’ and ‘unregimented’. She was able to go for meals with a friend and another service user said that she walked to the shops most days. A relative said that she was able to visit when she wished and was happy with the arrangements. One service user had an early lunch in their own room, as a GP was due to visit and it was expected that this would coincide with the serving of lunch in the dining room. The manager said that two or three other service users usually had meals in their rooms. Service users who were asked did not know what was to be served for lunch. The manager said that is was planned to return to having a menu board on display outside the dining room. There were set courses for lunch, but service users said that their likes and dislikes were known to staff and they would be offered an alternative if needed. This was evident during the lunch meal when quantities were also measured according to individual preference. After the sweet course some service users finished the meal with cheese and biscuits. Several service users expressed their satisfaction with the meal and no concerns were raised. The home was commended when standard 15 was last inspected and the meal arrangements continue to be given very good attention. Old Vicarage (The) DS0000059130.V253445.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): 16 and 18 Complaints are not being generated. Staff members have an awareness of abuse that helps to protect service users. EVIDENCE: A written complaints procedure has been produced. The manager said that a file for complaints was kept, although none had been received. The service users spoken with said that they had not had reason to complain, but felt that they could talk to the home’s manager or care manager if needed. Sometimes, service users talk to their keyworkers. Two staff members spoke about their awareness of abuse. One of the staff members had started since the last inspection and said that the subject of abuse had been included in her programme of induction. The other staff member had worked in the home longer and said that she had watched a video related to the ‘No Secrets’ guidance on the protection of vulnerable adults. This video was kept as a training resource in the home’s office. The staff member also said that she had seen a copy of the ‘No Secrets’ booklet, but had not been given her own copy. Abuse is included in the home’s policies and procedures file and in Staff handbook. The manager has produced a form to use in staff appraisals, which includes abuse awareness as a subject that needs to be discussed. The manager said there is a policy that male staff members do not provide personal care to female service users. Old Vicarage (The) DS0000059130.V253445.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 The location of the home and the service users’ individual accommodation is meeting their needs. EVIDENCE: The home is in a quiet street, but close to the town centre shops and amenities that several service users use. The Old Vicarage is an old property that is well decorated and retains many of its original and period features. Lifts are available between floors. The communal rooms looked well furnished and presented. Hygiene and infection control arrangements were not examined, but the rooms seen during the inspection looked clean and tidy. Some new MDF radiator covers have been fitted but not yet painted. Since the inspection, Mr Williams has reported that any room that becomes vacant will have had the radiator covers painted and that those that remain unpainted are as a result of the individual service user’s choice. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 15 Service users said that they get support from keyworkers with looking after their own rooms. Service users looked settled in their accommodation and said they had the facilities they need. A feature of the rooms is the amount of personal possessions and items of furniture that service users have been able to bring with them. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 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 Service users receive the support that they need. Staff members have clearly defined roles and there is an effective keyworker system. The lack of a POVA check was a significant omission in the recruitment of one new staff member. Service users benefit from the attention that is being given to staff training. EVIDENCE: A recorded staff rota was available. Additional staff members were on duty at peak times of activity. The manager said that there had been an increase in staff hours in response to the service users’ higher dependency levels. Service users said that staff are readily on hand if needed. Staff members have a dual role, which includes giving personal care and the carrying out of cleaning tasks. Service users commented on the keyworker system, which means that each person has a main carer from the staff team. Service users were familiar with their particular keyworker. The two staff members spoken with were both in the role of keyworker and appeared to have a good understanding of their responsibilities. The home was commended at the last inspection for the number of staff members who have achieved National Vocational Qualification at level 2. This Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 17 has progressed further and the home now has over 90 qualified staff. A number of staff members are now working on their N.V.Q. at level 3. The staff members reported on different training activities that they had attended. Courses in food hygiene, moving and handling and health & safety have been held since the last inspection. An induction checklist is completed with new members of staff and one staff member met with had completed an induction programme to T.O.P.S.S. standards. There is a low turnover of staff, with one care staff member and a kitchen assistant having been appointed since the last inspection. Employment records for the care staff member showed that proof of identity and written references had been obtained. The staff member started work in the home without a P.O.V.A. check having been carried out and there was a delay of some months before the outcome of her C.R.B. was known. This was discussed with the manager who said that she was now familiar with the system of P.O.V.A. checks, but had not appreciated that the scheme was already in operation when the staff member in question was appointed. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 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 The home is being run by an experienced manager who is gaining relevant qualifications. EVIDENCE: There is a well established management team and Cheryl Williams has managed the home for approximately 15 years. Cheryl Williams is progressing with obtaining the qualifications that are expected of a registered manager. Cheryl Williams said that she was waiting for verification of her registered managers award and was also completing her NVQ at level 4 in care. The care manager has also undertaken relevant qualifications in management and care. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 20 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 OP29 Regulation 19 Requirement A P.O.V.A. check must be undertaken before a staff member starts working in the home. Timescale for action 04/10/05 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 OP8 Good Practice Recommendations That health appointments and any follow-up action are clearly highlighted within the records. This will enable changes in health care to be more easily identified and monitored. A separate form for the recording of health related matters could be beneficial and used to achieve the same result. Old Vicarage (The) DS0000059130.V253445.R01.S.doc Version 5.0 Page 21 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 © 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) DS0000059130.V253445.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. 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