Inspection on 12/05/05 for The Old Vicarage Residential Home

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Old Vicarage Residential Home 06/01/09

The Old Vicarage Residential Home 22/12/08

The Old Vicarage Residential Home 31/07/08

The Old Vicarage Residential Home 26/09/06

The Old Vicarage Residential Home 25/10/05

The Old Vicarage Residential Home 26/11/04

The Old Vicarage Residential Home 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Old Vicarage Residential Home Limited Silver Street Whitwick Leicestershire LE67 5EW Lead Inspector Bhavna Keane-Rao Unannounced 12th May 2005 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 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 Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Old Vicarage Residential Home Ltd Address Silver Street Whitwick Leicestershire LE67 5EW 01530 831802 01530 831802 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Old Vicarage Residential Home Ltd Mrs Renu Sood Care Home 19 Category(ies) of OP - Old age (19) registration, with number of places Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26/11/04 Brief Description of the Service: The Old Vicarage residential home is a gothic grade II listed building, providing care for up to 19 people. It is registered to provide care for people who need care due to old age. The home is situated in quiet and secluded large gardens and is in the heart of the village of Whitwick in Leicestershire. All rooms are single, majority with en-suite. Almost all bedrooms are decorated to an acceptable standard. These are situated on the ground and first floor. There are two lounges a dining room and a kitchen. The gardens are well tended and reflect the different interests of the service users. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during a Thursday morning and early afternoon. A number of residents were spoken with, but detailed discussions were only held with three of them. One resident did not wish to be disturbed. A tour of the premises was undertaken and the opportunity was taken to view residents daily records, menus of meals, fire records, a staff rota and staff records. The registered owner and the registered manager spent time discussing many issues that arise in the running of a residential home and facilitated this inspection. What the service does well: What has improved since the last inspection? Since the last inspection the registered providers have employed a registered manager. The manager has been able to implement number of policies and procedures and has also been able to provide the residents and the staff with stability and leadership. The home has recently, 19/05/05, received the Investors in People Award. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 standard(s) 2,3,5 and 6 Information about the home is provided from the earliest opportunity and at regular intervals so that informed choice can be made. The admission process is well managed and reflected in the records. Residents entering the home are not always assessed so that their needs can be met. EVIDENCE: Examination of the Statement of Purpose indicated that the document accurately describes the services provided in the home. The admission procedure is adequate in that assessments of individuals are carried out by health and/or social care professionals, as part of the referral process. Four service users files were viewed they detailed the specific care needs of service users, identifying the needs that would be met by heath and/or social care professionals. One resident’s files indicated that this person was visually impaired and was wheelchair reliant. The registered manager’s initial assessment indicated this Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 9 to be the case. This is out of the home’s categories of registration. This is not acceptable and therefore a requirement has been made. Two relatives who were spoken with who were aware of the homes’ brochure. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 standard(s) 7,8,9 and 10 Residents’ health care needs are not totally met. Management of medication in the home is good. Residents receive their medication timely. Recording is accurate and clear. Residents’ privacy is not always upheld. Residents are treated with respect. EVIDENCE: Residents and their relatives who were spoken with were very happy with the provision of care and in particular with the staff in the home. Visiting health care professional were also asked about the care provision at this home. They were all very positive about the home and the provision of care. On the day of the inspection the audiologist was at the home. It was noted that staff do not knock on bedroom doors before entering. The number of falls is unsatisfactory indicating a lack of risk assessments and oversights in the provision of care. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 11 Recording in the residents’ plans of care and daily records were viewed and showed the following areas of concerns: • The daily entries are very brief • Care plans are not used to provide appropriate care to residents e.g. where a residents diet is noted as to be monitored in the care plan, it is not mentioned thereafter in any records. • Where a resident is constantly refusing to eat this is not followed up in care plans or daily records. • Risk assessments have not been carried out on areas of identified concerns. • Areas of concerns with regard to falls are not followed up in the care plans. • Not all the care plans have been completed yet. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 standard(s) 12,13,14 and 15 Residents’ religious preferences are catered for. Residents’ relatives are happy with the choice and input that they are given in the provision of care. Staff ensure residents are given stimulation and their recreational needs are met. Residents receive a wholesome and balanced meal. EVIDENCE: Staff undertake activities with residents both individually and in groups. Residents spoken with gave examples of how the home satisfies their choice of daily living at the home, the social and recreational interests. One person likes to go to the pub everyday and this is accommodated. Residents were seen receiving visitors and comments received included “she is well cared for and is happier”. Also “ She would not be here if she had not moved to this home”. Residents were observed moving freely around the home, some with the assistance from the staff. There are regular residents and relatives meeting held at the home, for those who wish to attend, where Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 13 information about events and changes to the home are shared and any matters of concern about the home are raised. There is a notice board where the activities to be provided during the week is displayed. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 standard(s) 16 and 18 Residents are confident in discussing any issues of concerns with the staff or the manager before it leads to a complaint. Adult protection procedures are in place and staff and the residents are trained to respond to any suspicion or allegation of abuse. EVIDENCE: Residents and visitors comments showed that people feel very comfortable discussing any concerns with the home’s manager. The complaints procedures are available for residents and visitors. Residents spoken with felt they were safe and protected. The new adult protection procedure has been introduced and staff spoken to showed their awareness of their duty to alert a senior member of staff. A number of residents also undertook the Awareness of Elder Abuse course. This is considered to be a very good working practice. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 A comfortable, well-maintained and safe standard of accommodation is generally provided for the residents. The areas of residents’ dignity must be addressed with regards to offensive odour in bedrooms. The atmosphere in the home is warm and welcoming. EVIDENCE: Two relatives of residents who were spoken with were very positive about the service provided by the home and in particular with the bedrooms belonging to their relatives. A visiting social worker was also spoken with who stated that the person she had come to see was very happy with her bedroom and with all the communal areas. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 16 The residents who were spoken with were very pleased with their bedrooms and were observed using the communal areas freely. Areas in need of work, identified at this inspection are as follows: • • • • One identified bedroom had strong offensive odour. The carpets in two bedrooms to be cleaned. The doorframe of the downstairs bathroom is damaged. The carpet in the hallway, outside the kitchen area, torn and is still sliver taped. This is outstanding from the last three inspections. It is noted that permission had to be obtained before any work could commence on this listed building. This has now been done. Quotes have now been received but orders have not yet been placed. Discussion was held with the owners regarding this and the fact that the Commission has been reasonable and fair thus far, but now this matter must be dealt with by the stipulated time or regulatory action may be taken. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The staff at the home are competent and able to provide for the general care needs of residents at the home. The staff members try hard to ensure that they meet the care needs of residents. EVIDENCE: On the day of the inspection there were three members of staff on duty, including the manager. This was satisfactory to meet the care needs of the residents at this home at the time of the inspection. Staffing rotas were examined, which are up to date and reflect the staff on duty. There is ongoing training to ensure that all the staff are providing high quality care. Staff are provided with all mandatory training. This is recorded in their individual files. All the staff are to be provided with refresher first aid training in June 2005. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38 Residents are regularly consulted about the running of this home. Residents and staff’s health, safety and welfare is not always promoted and protected. The manager is approachable to the staff and the residents and has an ‘open door’ policy. EVIDENCE: Residents Meetings are held regularly and minutes of the recent meeting were viewed. Residents can choose to attend. Information and events are shared with the residents both verbally and on the activities board. Residents have the opportunity to make suggestions on matters of interest or concerns both formally and informally during discussions with staff. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 19 Records of residents’ valuables and cash are accurately detailed and up to date. The home has a maintenance programme for all equipment used. A random sample of records checked was generally up to date including fire drills. The fire alarms are not tested as per the homes’ Fire Risk Assessment. During the tour of the home, fire exits were clearly marked and were not obstructed. Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 2 Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 21 Are there any outstanding requirements from the last inspection? 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. 2. Standard 3 7 Regulation 9,12 12,13,15 Requirement It is required that no residents are admitted to the home out of the homes registered category. It is required that daily records reflect the provision of care for residents. In particular any significant event must be recorded along with the action taken. It is required that care plans are reviewed and up dated as and when the care needs of residents changed. It is required that care plans are used by staff on the provision of care for the residents. It is required that risk assessments are carried out on all identified areas of concern. It is required that all falls are monitored and risk assessments are carried out to minimise these. It is required that staff always knock on residents doors before they enter residents bedrooms. It is required that doorframe of the downstairs bathroom must be repaired. The registered providers are required to replace the damaged Timescale for action Immediate Immediate 3. 7 15 Immediate 4. 5. 6. 7 8 8 13,15 13 13 Immediate Immediate Immediate 7. 8. 9. 10 24 25 12 23 23 Immediate 20/06/05 01/06/05 Page 22 Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 10. 11. 12. 26 26 38 16 16 23 carpet outside the kitchen area. This has been raised at the last three previous inspections. It is noted that this work is planned for beginning of the new year.This is still outstanding from last three inspections. It is required that bedrooms are Immediate regularly cleaned. It is required that problem of Immediate offensive odour in a bedroom is dealt with. It is required that fire alarms are Immediate tested at the frequency as per the homes’ own Fire Risk Assessment. 13. 14. 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 None Good Practice Recommendations Old Vicarage Residential Home Limited C51 S59863 The Old Vicarage Residential Home Ltd V226924 120505.doc Version 1.30 Page 23 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX 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. 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