Inspection on 30/11/05 for Vicarage Court Nursing Home

This inspection was carried out on 30th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Vicarage Court Nursing Home 10/06/09

Vicarage Court Nursing Home 05/06/08

Vicarage Court Nursing Home 01/06/07

Vicarage Court Nursing Home 15/09/06

Vicarage Court Nursing Home 27/07/05

Vicarage Court Nursing Home 12/01/05

Vicarage Court Nursing Home 07/07/04

Vicarage Court Nursing Home 16/03/04

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

CARE HOMES FOR OLDER PEOPLE Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG Lead Inspector Pam Grace Unannounced Inspection 30th November 2005 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vicarage Court Nursing Home DS0000022382.V270563.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. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vicarage Court Nursing Home Address 160 High Street Chasetown Staffordshire WS7 8XG 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) 01543 685588 01543 677034 Morecare Limited Mrs Ellen Elizabeth Wootton Care Home 39 Category(ies) of Physical disability (39), Physical disability over registration, with number 65 years of age (39) of places Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability (39) - Minimum age 60 years on admission Date of last inspection 27th July 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 Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was carried out over one day by one inspector. A tour of the home was undertaken and discussions were held with service users, visitors and staff. Discussions were also held with the registered manager of the home. Relevant records and documentation were examined. The registered manager assisted the inspector throughout the inspection. At the end of the inspection, feedback was given to the manager, outlining the overall findings of the inspection, and the requirements made. Service users spoken with were very positive about the care they were receiving. There were also service users who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. Conditions in the home were determined by direct observation, and sampling other services provided, such as medication, and aspects of health and safety measures. The staff and service users were thanked for their co-operation and open willingness to contribute to the inspection process. Three of the four previous requirements were met. Four requirements were made as a result of this unannounced inspection. What the service does well: Staff demonstrated great respect for service users, and service users were addressed in an appropriate manner. Service users and visiting relatives spoken with confirmed their satisfaction with the services provided at the home. 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 Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 6 Service users and visiting relatives spoken with confirmed that service users individual needs and wishes were well met. This was also evidenced by the comprehensive care plans seen. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Vicarage Court Nursing Home DS0000022382.V270563.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 Vicarage Court Nursing Home DS0000022382.V270563.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): Standards 2,3,4 Service users and or their representatives are assured that the home would be able to meet their assessed needs. EVIDENCE: There were 36 service users living at the home at the time of the inspection. Discussion with visiting relatives, 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, however some of these were not up to date, and care plans were not signed. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 9 Visiting relatives commented positively about the services their relatives received. Comments included the quality of the food at the home, the laundry service, and how well staff had cared for their relatives. The home’s administrator confirmed that all service users have received a written contract/statement of terms and conditions. The manager confirmed that service users are informed in writing that their assessed needs will be met by the home. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 Appropriate arrangements are in place for identifying and meeting the health and personal care needs of service users in the home. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service user care plans were sampled and examined. They evidenced that individual health, personal and social care needs had been established, and were being met. However, it is required that all care plans are reviewed monthly, and that they are signed by the service user and or their representative. Service users and visiting relatives spoken with said they were satisfied with the services they and their relatives received. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 11 There was a safe system in place for the receipt, storage, administration and disposal of medicines. Medication Administration records were checked and found to be in good order. Each service user had a photograph on their file, and all medication checked was correctly labelled and dated. Controlled Drugs were checked, and these tallied with stock levels held. There were no service users administering their own medication at the time of the inspection. The inspector noted during the inspection that service users were treated with respect and their privacy was upheld. Staff were seen to knock on service user’s bedroom doors prior to entering, and waited for consent to open the door. The inspector noted how well service users appeared, and how happy the atmosphere was in the lounge areas. Staff interacted appropriately and professionally with those service users. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 13,15 Service users maintain contact with family, friends, their representatives and the local community as they wish. The quality and variety of food served at the home is of a good standard, and menus reflected the wishes of service users, as well as the changes in season. EVIDENCE: There was evidence from talking to service users and visiting relatives 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. All kitchen areas were inspected, and were clean and hygienic. There had been a recent visit by the Environmental Health Officer, the outcome of which was that new thermostatic controls were to be fitted to the fridges. This was undertaken, and these were in place on the day of the inspection. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 13 Food hygiene standards were in place with regular checking of food temperatures and good food storage/control. A four weekly menu is maintained, providing a well-balanced and nutritional diet, with special diets catered for. Service users spoken with confirmed that they enjoyed the meals at the home, and that they are regularly consulted regarding their preferences. This is undertaken on an individual basis by staff. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 home has a clear complaints policy and procedure. This is on display in the main entrance of the home. CSCI had received one complaint about the home since the previous inspection. This was discussed with the manager during the inspection and satisfactorily resolved. The inspector noted that complaints received by the home are appropriately investigated and that timescales are in line with the home’s policy and procedure. Service users and relatives spoken with said that they had no cause to complain at present, but commented that they would speak to the home manager or one of the nurses if they needed to. They were aware that the home has a complaints procedure. Staff induction and in-house training programmes clarify the responsibilities of all staff in relation to the protection of service users from abuse. Staff spoken with, were aware of the home’s whistle-blowing policy, and the policies and procedures in place for the protection of service users. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21 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. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 16 The manager confirmed that the home has an ongoing programme of maintenance, redecoration and refurbishment. Following a tour of the building, the Inspector reported to the manager that the laundry floor needs repairing, some light pull cords need replacing, and an appropriate bin is required in the downstairs sluice. Paper hand towels were available for use throughout the home. However, these were not housed in the dispensers provided. The manager confirmed that arrangements were being made for new wall mounted dispensers to be ordered, as the key to the existing dispensers had been lost. These will be monitored at the next inspection. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 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 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): Standards 30 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: Staff spoken with confirmed that they had attended various appropriate courses. However, 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 requirement of this report that all staff should receive a minimum of 3 paid days training per year. The Inspector requested a copy of the home’s training records. The two cooks and kitchen staff spoken with confirmed that they had not received refresher training in food hygiene, and one staff member had not received any training in food hygiene. It is a requirement of this report that all kitchen staff must receive appropriate food hygiene training. Staffing levels were seen to be appropriate to the number of service users in residence at the home. The manager confirmed that existing staff members try to cover shifts that other staff would be unable to undertake, due to sickness or holidays. Vicarage Court Nursing Home DS0000022382.V270563.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): Standards 31,36,37 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. Staff are being appropriately supervised. Service users benefit from the way in which the home is managed, and the home is run in the best interests of the service users. EVIDENCE: The home’s Care Manager is a qualified RGN, is registered with the Commission for Social Care Inspection, and has achieved the NVQ level 4 Award in Management. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 19 Staff and service users spoken with talked about their confidence in the Care Manager’s ability to manage and run the home. Service users and their relatives said that they trusted and respected the manager, and the staff at the home. The manager demonstrated a knowledgeable and empathic relationship towards service users, visiting relatives, and staff. The inspector viewed records in relation to staff supervision, and spoke with staff. Supervision is now underway, and efforts are being made to ensure that this is undertaken as per the National Minimum Standard. The manager and staff spoken with confirmed that staff had received mandatory health and safety training, including regular fire drills, moving and handling. However, It is a requirement of this report that all staff should receive a minimum of 3 paid days training per year. Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 3 X Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(sch3) Requirement Care plans must be reviewed monthly, and signed by the service user or their representative. The laundry floor must be repaired. Broken light pull cords repaired. Bin in downstairs sluice must be replaced. Paper hand towel dispensers throughout the home must be replaced. Staff must receive a minimum of 3 paid days training per year. (Previous timescale of 30/10/05 not met) The cooks and kitchen staff must receive appropriate training and updates in food hygiene. Timescale for action 31/01/06 2. OP19 23(b) 31/03/06 3. OP30 18(a) 31/03/06 4. OP30 18(a) 31/03/06 Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Stafford Office 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 © 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 Vicarage Court Nursing Home DS0000022382.V270563.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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