Inspection on 05/06/08 for Vicarage Court Nursing Home

This inspection was carried out on 5th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Vicarage Court Nursing Home 10/06/09

Vicarage Court Nursing Home 01/06/07

Vicarage Court Nursing Home 15/09/06

Vicarage Court Nursing Home 30/11/05

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG Lead Inspector Pam Grace Key Unannounced Inspection 5th June 2008 09:00 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.V368528.R01.S.doc Version 5.2 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.V368528.R01.S.doc Version 5.2 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@tiscali.co.uk Morecare Limited Manager post vacant 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.V368528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability (39) - Minimum age 60 years on admission Date of last inspection 1st June 2007 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. Fee information is not included in this report, as this was not available at the time of the inspection. The reader may wish to obtain more up to date information from the care service. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was carried out over two days, by one inspector. The inspection had been planned using information gathered from the Commission for Social Care (CSCI) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the acting care manager and operations manager, comments/surveys received from people who use the service and their relatives. The acting care manager has since left the home, and this post is currently vacant. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, people who use the service and their visiting relatives. A tour of the environment was also undertaken. The Statement of Purpose and Service User Guide were available for us to view. However, both documents need reviewing and updating. In view of this, we advise that prospective people should visit the home, and ask relevant questions prior to making any decisions to move into the home. The previous inspection report is available to read in the main entrance hallway of the home. At the end of our inspection, feedback was given to the operations manager, outlining the overall findings of the inspection, and giving information about the requirements and recommendations that we would make. The home is currently advertising for the post of Care Manager, which is vacant. People spoken with were very positive about the care they were receiving. We observed people who were unable to communicate. Our observations showed that these people were well cared for, and were happy in their surroundings. There had been 2 complaints made to the home, since the previous inspection, these were not upheld, and had been dealt with in a timely way under the home’s complaints procedure, by the acting care manager. One anonymous complaint had been received by CSCI since the previous inspection. This was discussed in detail during the inspection visit, and was not upheld. Surveys returned to the Commission for Social Care Inspection (CSCI) totalled 7 x `Have Your Say’ documents. The feedback and comments we received from people about the service were generally positive, however some feedback Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 6 highlighted the need for more activities and better staffing levels. These comments have been included in this report There were 2 requirements, and 9 recommendations made as a result of this unannounced inspection. What the service does well: What has improved since the last inspection? What they could do better: The home continues to be without a permanent registered care manager. This makes change and improvement more difficult to manage, and affects the overall quality rating for this service. To comply with legislation and ensure effective management is sustained a manager should be appointed and registered. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 7 Prospective people wishing to use the service should have up to date information in regard to what services are provided. This includes the Statement of Purpose and Service User Guide. A system should be implemented for the routine checking of health and safety within the home. All medication must be signed for. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The policy and procedure for medication administration should be reviewed. Risk assessments should be kept under review and be updated to reflect any changes in the individual’s condition. Clearer and more easily accessible menus should be available at all times for people who use the service. Choices of meals should be clearly written for people to see. Care plans would benefit from the recording of the person’s social history, i.e. lifestyle, hobbies and interests prior to moving into the home. This would enable a care plan that is more tailored to the person’s needs. People who use the service should be consulted about the programme of activities arranged by or on behalf of the care home, and be provided with facilities and activities for recreation, fitness and training. Staffing numbers should be regularly reviewed, and should be appropriate to the assessed needs of people who use the service. A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and resident’s meetings. People who use the service should have a forum for having their say in regard to the running of the home, and there should be feedback given in regard to quality assurance outcomes. 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. The summary of this inspection report can be made available in other formats on request. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 - Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People considering using the service and their representatives should be provided with up to date information, which helps them decide if the service will be suitable to meet their needs. No person moves into the service without firstly having had their needs assessed. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the acting care manager, told us: “Vicarage Court continues to service the people of the community and surrounding areas. Vacancies/enquiries are always from people and social workers who have recommended the home, for its locality and good feedback from families of previous residents. We have recently allocated 2 beds for continuing care-funded clients Macmillan Nurses have commented on the care Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 10 that the service users receive. We do not have to advertise the home to fill vacancies”. We were given copies of the Statement of Purpose and Service User Guide to look at. We saw that these documents had been reviewed, but that they did not meet the National Minimum Standard Schedule 1, and some of the information was out of date. This was highlighted and discussed with the operations manager at the time. People spoken with, and feedback from surveys undertaken confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. People also confirmed that they had been provided with a contract/terms and conditions. Contracts were in the process of being reviewed. We looked at three care plans. These showed that a full assessment of needs had been undertaken for those individuals on admission The assessments gave good information about the person’s needs across all activities of daily living examples being; cognitive awareness, confusion, risk assessment including falls, bathing, moving and handling and fire safety. Intermediate care is not provided in this home. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Risk assessments should be kept up to date. Medication processes need further improvement to ensure that they are safe. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the acting care manager, confirmed the following: “Key worker (system) is implemented to support service users with all their personal care. Outside services are still available for the service users e.g Optician, dentist, chiropodist, physiotherapists and dieticians. Staff are encouraged to use the services of other nursing professionals such as nurse specialists and members of the MDT to ensure that the best possible care is maintained for those service users needing Palliative/specialist care. Our Nurses continue to work in conjunction with the community physiotherapists to encourage mobility. Feed back from the McMillan nurses and the Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 12 physiotherapists documentation in care plans, The home has recently been able to allow a 91yr old lady to return to her home after successfully rehabilitating her with the support of community physiotherapists. We have arranged further training for the staff with the McMillan Nurses to start end of May for 4 weeks.” We examined three care plans. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each of these people were to be cared for, what these staff told us reflected what was written in individuals care plans. People we spoke to told us they had been involved in their care planning processes and their review. All three care plans contained evidence of a pre-admission assessment, which had informed the care plan. There was also evidence of health professional’s involvement, for example physiotherapy, stroke nurse and dietician. No details were recorded in the event of terminal illness. Some assessments were undated, so it wasn’t clear when they were reviewed. This was highlighted and discussed at the time with the operations manager. The operations manager confirmed that the tissue viability specialist nurse would be consulted where necessary in relation to a person requiring more complex treatment. Daily records seen confirmed in one instance that bathing had not been undertaken “due to staff shortages” This was highlighted, and discussed in detail with the operations manager, and in regard to individual preferences and staffing levels. People spoken with during our visit said that they were very satisfied with the care they receive, and that they were only to ask for help, and staff gave them help. One person confirmed her satisfaction with the care she was receiving, she said the staff were very good, kind and considerate. She said she was “pleased with her room”, and realised that she “was now quite poorly”, but said she “was getting the support she needed from staff and her GP/McMillan Nurse”. She said she “sometimes has to wait for staff to come, but she realised she was not the only person needing help”. During a spot check of medication, we discovered that some medication had not been signed for on the Medication Administration Record (MAR). An emollient cream previously prescribed for a deceased person was found on a dining table in the dining room upstairs, during a tour of the building. We recommend that the medication administration policy is reviewed. These shortfalls were highlighted and discussed with the operations manager during our inspection. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 13 The home understands the need to comply with the administration, safekeeping and disposal of controlled drugs. Medication systems do not always follow good practice or safe practice guidelines and has needed action. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service should be enabled to make choices about their life style and should be supported to develop their life skills. Social, educational, cultural and recreational activities must meet individual’s expectations. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the acting care manager, confirmed the following: “The care co-ordinator continues to arrange activities and outings for the service users. Outings are arranged to local attractions and family and friends also attend, Outside entertainers have also visited the home to celebrate special events – Easter, service users special parties etc. Activities also take place during the day such as film afternoons, games, discussions and singalongs. Service Users feedback that they enjoy the entertainment and the outings. Families and friends also are very supportive of all the events.” The AQAA implied that there had been an activities co-ordinator in post for some time, however, our enquiries did not confirm or evidence that. For Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 15 example there were no library books available for people to read, there were very few activities resources around the building for people to use. We spoke with a staff member who had recently been asked to undertake the role of activities co-ordinator. She confirmed that following training, she will be undertaking activities 6 hours weekly, which will be split over 3 x 2 hour sessions. We discussed the need to record activities undertaken by individuals, and the need to identify people’s needs prior to implementing new activities. People spoken with and surveys received confirmed that people using the service had missed their activities, and were looking forward to the new coordinator starting. Most people said that “activities depended upon staffing levels”, and felt that staff were often “hard pushed to find the time to spend just for a chat, let alone organising an activity”. People spoken with confirmed that they were unable to have their say, as there were no resident’s meetings. People who use this service are not able to achieve their full potential. Independent living skills are not seen as important, and staff do not give time to working with individuals, helping them to learn and develop. It is considered by staff to be much quicker and easier to “do” for people. This could be because of current staffing levels. Four weekly rotational and seasonal menus were in place. We looked at the kitchen, which was very clean and tidy. The cook, and records seen confirmed that all hot food temperatures are taken daily and recorded, this is as well as fridge/freezer temperatures. We discussed the need to clearly record the choices of meals at each mealtime, so that people can clearly read what is on offer on the daily menu. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. EVIDENCE: We saw that the complaints procedure was displayed in the main entrance to the home. However, our address had not been updated, and the size of print was too small, making it difficult for people to see it clearly. This was highlighted and discussed with the operations manager at the time. The operations manager confirmed that people who use the service and or their representatives are provided with a copy of the home’s complaints procedure during the admission process. People spoken with during the inspection visit confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. A new grumbles book had recently been introduced. One relative spoken with said “if there are problems I come in and have a word. Matron is very approachable”. The operations manager confirmed that the home has an open door policy in regard to complaints. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 17 Discussion with the home’s owner/provider confirmed that he often speaks with people who use the service and or their relatives. He sorts out any problems straight away. That’s why he feels that the home does not receive many formal complaints. He confirmed that he has also recently introduced surgery type evenings for relatives, which are proving to be successful. The Annual Quality Assurance Assessment document completed by the acting care manager confirmed that the home had received 2 complaints since the previous inspection. Both complaints had been amicably resolved and appropriately documented and not upheld. Records were available for us to view. We had received one anonymous complaint about this service, which was discussed in detail during our visit, and dealt with by the operations manager. The complaint was not upheld. The operations manager was asked to provide us with a letter/report confirming the outcome of that complaint. There had been no Protection of Vulnerable Adults (POVA)/Safeguarding referrals made to Social Services since the previous inspection. We spoke with staff, they were unable to remember or confirm whether they had received update or refresher training with regard to issues of abuse, its identification and types of exploitation. It is a recommendation of this report that safeguarding/abuse training is undertaken by care staff. Staff recruitment records evidenced that appropriate Police checks had been undertaken prior to employment. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a well-maintained and comfortable environment, which encourages independence. However, a system should be developed to include daily health and safety checks of the environment, to ensure people’s safety. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the acting care manager, confirmed that all health and safety checks on equipment and fire systems had been undertaken, and confirmed the following: “The home has continued with its refurbishment program, nearly all the bedrooms have been redecorated along with the communal areas. The home continues to be odour free and the cleaning schedule is checked at regular intervals. The home has started to replace carpets in the lounge, dining room, Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 19 reception areas and bedrooms. We have replaced some bedroom carpets with specialist flooring to help with infection control etc. Curtains for the lounges and bedrooms have been on order and are expected to be delivered and fitted in the 3rd week of May.” People spoken with during the inspection visit expressed their satisfaction with the general environment, their room, and the equipment provided within the home. People spoken with said “it’s always nice and clean here”, and “the staff try very hard to keep it all clean”. “I’ve never seen a mess”. “I like my room, there’s no funny smell”. We undertook a tour of the environment. The home provides a clean, wellmaintained environment throughout. There were some areas highlighted and noted in regard to replacement of carpets, and refurbishment, however, these were already known to the operations manager, and were in hand. The main lounge carpet, and hall carpet downstairs had recently been replaced, and new curtains had been fitted in the downstairs lounge. Accommodation is personalised to suit individuals. Communal areas are comfortable and homely. Bathrooms and toilets are conveniently sited around the home. One bathroom on the first floor is now used solely for storage. However, this still leaves 3 bathrooms and a shower room for people to use. We noted that equipment and adaptations were provided as necessary to maximise independence. For example, wheelchairs, raised toilet seat, bed rails, pressure mattress, handrails, and assisted baths. Bed rail bumpers were in place where needed, to promote the comfort and security of the people using the service. Care plans showed that risk assessments were in place and up to date for those in use. Kitchen and laundry areas were clean and tidy, with appropriate measures in place to prevent cross infection. Outstanding issues in regard to Fire Safety Compliance were discussed with the operations manager. A copy of the home’s Fire Safety Compliance Certificate was requested, this should be forwarded to CSCI for our records. The following issues were highlighted and discussed with the operations manager and the provider at the time: * A disposable razor was found in the shower room on top of the shower fitting. This was a potential injury hazard. The room should have been checked following use. * The lift maintenance cupboard, which is marked “danger”, was left unlocked following an engineer’s visit the week before. This should have been checked and kept locked. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 20 * One cupboard was stacked so high with bedding that the door would not close. There was also electrical equipment on the wall inside the cupboard. This was a potential fire hazard. * The bathroom on the ground floor had a mattress placed against the wall, and a pressure mattress was left folded on the floor. These were inappropriately stored, and posed a trip hazard for staff and for people using the service. * There were no paper towel dispensers throughout the home, and toilet rolls were left on top of toilet cisterns. Bundles of paper towels were left exposed, and in proximity to sinks around the building. Increasing the risk of cross infection. * Continence pads were not properly stored in the cupboard. * Some wheelchairs in use by staff for transferring people with poor mobility had only one footplate in situ. This is unsafe practice. Both footplates need to be used. It was recommended that a system for monitoring health and safety in relation to the environment is established, ensuring the safety of the people who use the service. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff in the home should be trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the acting care manager, confirmed the following: “The rigorous recruitment process continues and the staff are inducted by the care co-ordinator over a period of time depending on their prior experience. Staff rotas are completed on a monthly basis and staff requests for off duty are generally met as this has proved to help with staff morale and has lowered the amount of absences. Staff retention has improved and staff sickness has shown a decrease over the past few months. A new rolling rota has been introduced after taking on board the comments of staff re- home and work balance. This rota allows the staff to have alternate weekends off enabling them to make plans for social/leisure activities”. Staff, people spoken with during the inspection visit, and surveys received, confirmed and highlighted the need for “better staffing levels”, and the “lack of staff available for toileting”. There had also been comments made in relation to lack of staff supervision of people during toileting, and whilst staff assist in Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 22 getting people up in the mornings. There was reportedly no staff member supervising the people in the lounge areas during this busy time. Care records seen for the month of March 2008 showed that bathing for some people had not been undertaken because of staff shortages. This has resulted in a poor outcome for people who use the service. Staff spoken with confirmed that staff meetings were being held 3 monthly, and that supervision of staff was being held every 8 weeks, as per the National Minimum Standard. They confirmed that they had received updates in regard to mandatory training, including moving and handling, health and safety, Fire and Medication. However, staff spoken with could not recall when they had last undergone training in relation to abuse/safeguarding of vulnerable adults. We requested a copy of the home’s staff training matrix. Staff said that they were not satisfied in regard to staffing levels, and confirmed that they had felt overworked and under pressure to complete all of their work even though residents’ needs had increased, and they were often short of staff due to illness or absence. Agency cover often resulted in making extra work for permanent staff, as agency staff “don’t tend to know the work routine at the home”, and “it takes time to explain how things work”. Three staff recruitment files were examined. They contained all the appropriate security/police checks, and evidenced a good standard of procedures from an administrative point of view. The staff rota for April, May and June 2008 confirmed that staffing levels are being maintained with agency cover as required. However, on discussion with the operations manager, it was agreed that staffing levels should be reviewed in line with the changes in people’s level of need. There needs to be a staff member supervising the communal areas when they are being used by people who use the service, there also needs to be enough staff to toilet and support people with their personal care. There should also be enough staff on duty to support people with activities each day. The home still needs a permanent registered care manager, this has yet to be achieved, and does affect the overall quality rating for the home. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 36, 37 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Short-term arrangements and management input by the operations manager is effective. The home should further develop its quality assurance system to make sure that services are provided in the best interests of those who use them. A system of monitoring health and safety in the home should be implemented as soon as possible. EVIDENCE: There had historically been no registered manager in post for the past year. The home still needs a permanent registered care manager, this has yet to be achieved, and does affect the overall quality rating for the home. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 24 The operations manager told us that she is responsible for the service at present. She told us during discussion that the organisation has been actively seeking to recruit to the care manager post. The Annual Quality Assurance Assessment (AQAA) document, which was completed by the acting care manager, was returned to the Commission for Social Care Inspection on time, and was completed to an adequate standard. The Annual Quality Assurance Assessment document confirmed the following: “We have purchased a new quality assurance system to gather and evaluate feedback from service users and their families. As it is in its early stage we are unable to evaluate at this early stage. Quality Assurance with Menus has proved to be valuable and changes to menus have carried on. Interim questionnaires are planned for early May where we will be able to give feedback on the new system in place. A new Care Planning system has been purchased and incorporates equality and diversity issues. E&D issues are always discussed at pre-admission and care planning all service users are treated as individuals. We are currently trying source/access a befriending service that will be able to help a resident with communication barriers. The home continues to employ 2 administrators to support nursing staff with the daily administration of the home, The acting manager has been allocated 2 administration days per week for the continuous improvement of the home. The acting manager has been supported by the quality manager with systems and procedures. When pre admission assessments are carried out the operations manager has been in attendance with the manager to ensure that admission is a smooth transition with equipment etc ordered”. The home needs to review and amend the statement of purpose and service user guide, in line with Schedule 1 of the National Minimum Standards. The operations manager is trying to improve and develop systems that monitor practice and compliance with the plans, policies and procedures of the home. More work however is needed in relation to Health and Safety monitoring of the environment, safe Administration of Medication, the Medication Policy and Procedure needs reviewing, and the Quality Assurance system needs to be fully implemented. There had been two complaints made to the home since the previous inspection. These had not been upheld. We had received one anonymous complaint about this service, which was discussed in detail with the operations manager and not upheld. The operations manager agreed to provide us with her outcome report in regard to that complaint. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 25 During a tour of the environment a number of health and safety issues were identified, including medication administration errors. A system of monitoring and ensuring safe practice should be implemented as soon as possible to ensure the safety of people who use the service. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 26 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 3 X 3 3 2 Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13(2) Sch 3(3)(i) Timescale for action The registered person shall make 05/06/08 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home The registered person shall 05/06/08 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated Requirement 2. OP38 13(4) 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 OP1 Good Practice Recommendations Prospective people wishing to use the service should have up to date information in regard to what services are provided. This includes the Statement of Purpose and Service User Guide. Risk assessments should be kept under review and be updated to reflect any changes in the individual’s condition. DS0000022382.V368528.R01.S.doc Version 5.2 Page 28 2. OP7 Vicarage Court Nursing Home 3. OP7 4. OP12 5. 6. 7. 8. OP27 OP30 OP31 OP33 9. OP38 Care plans would benefit from the recording of the person’s social history, i.e. lifestyle, hobbies and interests prior to moving into the home. This would enable a care plan that is more tailored to the person’s needs. People who use the service should be consulted about the programme of activities arranged by or on behalf of the care home, and be provided with facilities and activities for recreation, fitness and training. Staffing numbers should be regularly reviewed, and should be appropriate to the assessed level of needs of people who use the service. Staff should receive regular update/refresher training in regard to Safeguarding and Abuse of Vulnerable Adults. To comply with legislation and ensure effective management is sustained a manager should be appointed and registered. A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and resident’s meetings. A system should be implemented for the routine checking of health and safety within the home. Vicarage Court Nursing Home DS0000022382.V368528.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V368528.R01.S.doc Version 5.2 Page 30 - 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. 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