CARE HOMES FOR OLDER PEOPLE
Vicarage Court 160 High Street Chasetown Staffordshire Staffs, WS7 8XG Lead Inspector
Pam Grace Unannounced 27 July 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. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Vicarage Court Nursing Home Address 160 High Street Chasetown Staffordshire Ws7 8XG 01543 685588 01543 677034 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) Morecare Limited Mrs Jacqueline Anne Stobbs Care Home 39 Category(ies) of PD 39 registration, with number PD(E) - 39 of places Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1) Physical Disability (39) over 60 years Date of last inspection 12 January 2005 Brief Description of the Service: Vicarage Court is a 39 bedded care home with nursing, situated in Chasetown. It comprises of a purpose built building set in a town location, and close to a local shopping centre, and is also on a bus route. The proprietors Morecare Ltd., have run the home since it was first registered in 1995. The home is currently registered to admit 39 elderly service users over the age of 60yrs, and comprises of single and double bedrooms, some of which have en-suite facilities. There are two lounge and dining rooms; other facilities include a hairdressing salon and conservatory. All areas of the home have access to a passenger lift. There are car parking facilities. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was undertaken by one Inspector over a period of approximately 5 hours, with the assistance of the home’s Care Manager. There were 38 service users in residence at the time of the inspection, including 3 residential service users. The inspector spoke with the Responsible Person, several staff members, a visiting relative, a health professional, and many service users during the inspection. Service users spoken with were very positive about the care they were receiving, there were also some service users who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. The inspection undertook a tour of most areas of the home, and a number of records and documents were examined. Conditions in the home were determined by direct observation, and sampling other services provided, such as laundry, organised activities, and aspects of health and safety measures. There were 4 requirements and 1 recommendation made as a result of this inspection, some of which had not been met, and were outstanding from the home’s previous inspection. These were discussed and clarified, and appropriate steps are to be taken by the home to ensure that those outstanding are met within the stated timescales. The staff and service users were thanked for their co-operation and open willingness to contribute to the inspection process. What the service does well:
Staff demonstrated great respect for service users. Service users were addressed in an appropriate manner, and service users spoken with confirmed their satisfaction with the services provided at the home. The home has a robust recruitment procedure. This was evidenced within staff records examined. Health care awareness was evident, with the importance of any changes in health status, being continually monitored by appropriately trained, caring and diligent staff.
Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 6 Service users individual needs and wishes were well met. Service users and relatives spoken with were pleased and satisfied with the care provided by the home. What has improved since the last inspection? What they could do better:
Further development is required in relation to Quality Assurance, room audits were in place, and being monitored regularly by the Care Manager, however, this needs to be expanded to include service users’/relatives and or representatives’ views, and visitors/health professional’s views. Regulation 26 reported visits - the Inspector spoke with the Responsible Person about appropriately recording their visits to the home. The Responsible Person confirmed that the home is visited regularly, however, a format for reporting is needed to enable this to be done. The home’s Care Plans were up to date, and contained appropriate information. However the format used, and the way in which the Care Plan is set up, is very disjointed, and difficult to follow. The home’s Care Manager is planning to introduce a new format for Care Plans within the next few months. The Inspector spoke with some staff members. Staff spoken with, were not aware of what supervision is, the home must ensure that all staff receive appropriate supervision as per the National Minimum Standard. Some staff training is taking place, however, staff records seen showed that some staff would achieve their 3 days paid training per year, and some would not. It is required that all staff must be able to achieve this. This must also include mandatory training updates according to their role. One staff member had not received appropriate training in Infection Control, and COSHH procedures. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 7 The inspector recommended that the home’s Quality Assurance system be further developed. Questionnaires should be distributed to include other professionals visiting the home, and the outcome of the feedback from the overall survey undertaken should be recorded with a plan of action as appropriate. 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. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 8 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 Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 9 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) 1,3,4 Service users and or their representatives are assured that the home would be able to meet their assessed needs. EVIDENCE: There were 38 service users living at the home at the time of the inspection. Discussion with visiting relatives, a health professional, service users, and staff, evidenced that service users needs are being met, and that pre admission assessments were undertaken. This was also evident in care plans sampled, and daily records. There was evidence of specialist advice and treatment contained within care plans seen. Regular reviews were evidenced in care plans seen. A visiting relative commented positively about the quality of the food at the home, the laundry service, and was particularly pleased with how staff had cared for their relative. The home’s administrator confirmed that all service users have received a written contract/statement of terms and conditions.
Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.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) 7,8,10 Appropriate arrangements are in place for identifying and meeting the health and personal care needs of service users in the home. EVIDENCE: A random selection of service user care plans were examined. They evidenced that individual health, personal and social care needs had been established, and were being met. However it is a requirement of this report that all care plans must be clear, and more easily accessible. The Inspector noted that care plans seen were untidy, and some sections of the plan were kept in different places/files. This was discussed with the Care Manager at the time, and the Inspector noted that a new pro forma system for the Care Plans has been drawn up, and is to be implemented within the next few months. The Inspector noted that the specialist nurse for tissue viability had been consulted regarding advice on particular dressings, and or treatment of pressure area damage. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 11 The Inspector spoke with a visiting health professional about the home. The comments received were positive, and supported the view that the home does seek advice and support regarding service users’ health needs when appropriate. The Inspector noted how well service users appeared, and how happy the atmosphere was in the lounge areas. Staff interacted appropriately with service users, respecting their wishes. Staff were seen to knock on service user’s bedroom doors prior to entering, and waited for consent to open the door. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.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) 13 Service users maintain contact with family, friends, their representatives and the local community as they wish. EVIDENCE: There was evidence from talking to service users and a visiting relative that contact is maintained with family and friends on a regular basis. There were no restrictions placed on visiting times, and the home provides a relaxed and friendly environment. Visitors were seen arriving and leaving the home during the course of the inspection. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 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 standard(s) 16,18 Complaints and grumbles are listened to and resolved. The home’s policies, procedures and staff training protect service users from abuse. EVIDENCE: The inspector spoke with staff and service users. Service users spoken with said that they felt safe and secure in the home. Staff spoken with confirmed that they had received training in regard to abuse/vulnerable adults. This was undertaken during their TOPSS/ induction course, staff stated that they were also aware of the whistle blowing policy and the procedure for the reporting of abuse. The inspector viewed a selection of staff recruitment files. They evidenced that staff had undergone appropriate CRB and POVA checks prior to employment at the home. The home has a robust recruitment procedure. The Care Manager confirmed that the home had received one complaint since the last inspection. At the time of the inspection, this was in the process of being dealt with through the home’s complaint procedure. Staff spoken with confirmed that any complaints and grumbles are always listened to, and acted upon. They are usually resolved straight away. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 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 standard(s) 19,22,23,24,25,26 The location and layout of the home is suitable for its stated purpose. Service users live in a safe, clean and comfortable environment, which has been adapted to suit their lifestyle, and individual needs. EVIDENCE: The inspector undertook a tour of the home, which included all the communal areas. The home was found to be clean and well presented throughout. Bedrooms had been adapted to suit the needs of the service users and there was evidence of personal effects in bedrooms. Various aids and adaptations were in place including assisted baths, mobile hoists and other equipment used for moving and handling of service users. There was a nurse call bell in operation, which was heard to be working at the time of the inspection.
Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 15 Bedrails were used following a risk assessment. Bumpers were used with these. The registered provider confirmed that the home has an ongoing programme of maintenance, redecoration and refurbishment. The Inspector reported that a loose light fitting in the downstairs sluice room needed replacing. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 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 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) 27,28,29,30 Staffing levels at the time of the inspection were sufficient in numbers to meet service user’s needs. Staff are appropriately recruited to work at the home, and service users are protected by the home’s recruitment policy and practices. All staff must have a minimum of 3 paid days training per year, (including in house training), and have an individual training and development assessment and profile. EVIDENCE: At the time of the inspection there was a total of 38 service users resident in the home, 3 of which were residential level of care. Duty rotas were examined. * Early duty 0700 – 1400 was covered with 2 qualified and 6 care staff * Late duty 1400 – 2100 was covered with 1 qualified and 6 care staff * Night duty 2100 – 0700 was covered with 1 qualified and 3 care staff Staffing levels were seen to be appropriate to the number of service users in residence at the home. The Care Manager confirmed that existing staff members try to cover shifts that other staff would be unable to undertake, due to sickness or holidays. As well as nursing and care staff, the home employs ancillary staff consisting of housekeeping and laundry assistants, cook and kitchen assistant. There is
Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 17 also a maintenance person (shared with another home), a part time activities co-ordinator, and the home has administration support. The inspector interviewed staff members, and examined staff recruitment/training records. Staff spoken with confirmed that they had received appropriate training. This included in house induction training and TOPSS related courses at the local College. Records viewed showed that staff had received instruction on fire safety, fire drills and moving and handling training. However, one staff member had not received appropriate training in Infection Control, and COSHH procedures. The Care Manager noted this, and confirmed that this would be addressed. Records seen confirmed that some care staff would receive the minimum of 3 days paid training per year, and others would not meet that target. It is a recommendation of this report that all staff should receive a minimum of 3 paid days training per year. A random selection of staff recruitment files was examined, and there was evidence of a thorough and robust recruitment procedure including 2 written references, CRB and POVA check. All prospective employees are interviewed and employment history is obtained. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.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) 33,36,38 The home’s existing Quality assurance system should be further developed to include service users, their relatives/representatives, and visiting professionals. Care staff are not receiving supervision as per the National Minimum Standard required. The health, safety and welfare of service users and staff are promoted and protected. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 19 EVIDENCE: The Inspector discussed the existing Quality assurance system, and recommended that the system be further developed. The inspector viewed room audits, which give regular feedback to the Care Manager on the condition/maintenance of rooms within the home. Questionnaires should be distributed, to include the views of service users, relatives, and other professionals visiting the home. The outcome of the feedback from the overall survey undertaken should be recorded with a plan of action as appropriate The Care Manager confirmed that the Registered Person carries out quality control visits to the home. However, it is a requirement of this report that a monthly report in accordance with the requirement of Regulation 26 is completed and forwarded to CSCI. The format of this report was discussed in detail with the Registered Person. There was no evidence of regular staff supervision within staff files seen, as per the National Minimum Standard (NMS). The Inspector spoke with some staff members. Staff spoken with confirmed that they did not know what supervision was. This was discussed in depth with the Care Manager during the inspection. It is a requirement of this report that care staff must receive appropriate supervision as per Standard 36 of the N.M.S. Records relating to Fire alarm testing, detecting and fire fighting equipment were up to date, and had been appropriately serviced and tested. Records relating the testing and maintaining of the emergency lighting were up to date and had been appropriately completed. Accidents had been recorded as required and audited on a regular basis. Evidence was seen of regular staff mandatory health and safety training including regular fire drills and the staff spoken with confirmed this. Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.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 3 x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x
COMPLAINTS AND PROTECTION 3 x x 3 3 3 3 3 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 Standard No 16 17 18 Score 3 x 3 x 2 2 x x 2 x 2 Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 21 yes 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. 3. Standard OP7 OP30 OP32 Regulation 15(sch3) 18(a) 26 Requirement Care plans must be readily accessible and clearly recorded. Staff must receive a minimum of 3 paid days training per year. The registered person must ensure that a record of visits made under Regulation 26 are forwarded to the CSCI . (previous timescale of 12/03/05 not met) Care staff must receive formal supervision at least six times per year in accordance with the National Minimum Standard. (previous ongoing timescale not met) Timescale for action 30/10/05 30/10/05 30/10/05 4. OP36 18(2) 30/10/05 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. 2.
Vicarage Court E09 E51 S22382 Vicarage Court V240273 270705 Stage 4.doc Version 1.30 Page 22 Refer to Standard OP33 Good Practice Recommendations The registered person should expand the existing Quality Assurance system to include the views of service users, relatives, representatives and other professionals. Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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