Inspection on 16/11/05 for Vicarage Farm Nursing Home

This inspection was carried out on 16th November 2005.

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

The inspector 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 Farm Nursing Home 28/04/08

Vicarage Farm Nursing Home 21/08/07

Vicarage Farm Nursing Home 19/10/06

Vicarage Farm Nursing Home 22/05/06

Vicarage Farm Nursing Home 20/04/05

Vicarage Farm Nursing Home 16/12/04

Vicarage Farm Nursing Home 08/06/04

Vicarage Farm Nursing Home 17/02/04

Vicarage Farm Nursing Home 07/10/03

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

CARE HOMES FOR OLDER PEOPLE Vicarage Farm Nursing Home 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA Lead Inspector Paula Eaton Unannounced Inspection 16th November 2005 09:15 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 Farm Nursing Home DS0000010962.V257360.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 Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Vicarage Farm Nursing Home Address 139 Vicarage Farm Road Hounslow Middlesex TW5 0AA 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) 020 8577 4000 020 8572 1221 vicaragefarm@schealthcare.co.uk Southern Cross Healthcare (Management) Limited Care Home 62 Category(ies) of Dementia (0), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (0), Physical disability over 65 years of age (0) Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 35 mentally ill 27 elderly medically frail 5 patients with mental illness over the age of 50 (included in the total of 35) 20th April 2005 Date of last inspection Brief Description of the Service: The home is situated in a residential area of Hounslow. It is set back from the road and has good car parking facilities. There are local shops within walking distance. There are accessible local bus routes and the home is within ten minutes walk of Hounslow West underground station. The home is set on two floors. The ground floor provides accommodation for twenty-seven service users and the first floor provides accommodation for thirty-five service users. The home provides nursing care to older people with a wide range of needs including dementia, mental disorder and physical disability. There are fifty-four single rooms and four shared rooms in the home. There is a well-maintained central courtyard area with furniture suitable for service users and their visitors. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four and a half hours as part of the annual inspection process. The manager, four staff, six service users and a visiting relative were spoken to and records, policies and procedures were examined. The manager of the home has been in post for just over a year. It was evident that steady improvements have been made to the service provided at Vicarage Farm during this time. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that mandatory training takes place for staff to ensure the safety of staff and service users. It is also important that the service maintains the current level of service and continues to improve. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Vicarage Farm Nursing Home DS0000010962.V257360.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 Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 The home carries out satisfactory assessments of service users prior to admission to ensure the home is able to meet their needs. There are satisfactory systems in place to ensure the home is able to meet the assessed needs of service users. Prospective service users are given the opportunity to visit and assess the suitability of the home. EVIDENCE: The home carries out a pre-admission assessment and a more detailed assessment once a service user is admitted to the home. The information contained in the assessment documentation inspected covered all areas of need for each service user. The home had also obtained any Care Management assessments that had been completed. The homes assessment and the Care Management assessments had been used to develop care plans for the service users. A qualified member of staff had carried out all assessments. Staff are provided with appropriate training to assist them in providing needs based care for service users. Staff had received training in dementia care and the activities co-ordinator is able to access specific training such as training in arts and crafts to enable her to meet the social and leisure needs of service Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 9 users. The manager of the home acknowledged that the home could do more to meet the needs of service users cultural needs. She was in the process of reviewing the meal provision in the home to increase the variety of culturally specific foods for service users. The manager said that service users and/or their families are always invited to visit the home prior to being admitted to the home. A six week trial period then commences and then the placement is reviewed before being confirmed. Vicarage Farm Nursing Home DS0000010962.V257360.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): 7, 8, 9 and 10 Assessed needs had been incorporated into individual plans of care. Health care needs had been assessed and were being met. The systems for the safe administration of medication were generally satisfactory. Service users were being treated respectfully. EVIDENCE: Individual plans of care were available and were comprehensive. At the time of the inspection the care plans were being transferred to a new format. The care plans viewed were up to date and contained details of all areas of need. It was evident that care plans were being updated as the needs of service users changed. For example, the behaviour of one service user had recently changed. As a result a psycho-geriatrician had been consulted, a meeting had been held and the service users care plan updated and a risk assessment completed. All of the care plans viewed contained appropriate risk assessments with regard to falling and other areas of individual risk. These risk assessments were generally being regularly reviewed, however, it was noted that some of the risk assessments were not dated so it was difficult to assess when they had been completed. Daily records are maintained for each service user. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 11 Health care needs were outlined in the records examined and were incorporated into the care plans. Any health care appointments attended or treatment received had been recorded clearly. Appropriate assessments are carried out to ascertain a service users needs including assessments on nutrition, continence, moving and handling and risk of pressure sores. There are appropriate medication policies and procedures in the home. The manager said that she had been closely monitoring the medication procedures in the home. The medication administration record sheets were viewed and were up to date and in order. The storage of medication in the home was generally satisfactory and issues raised at the last inspection relating to the temperature of the medication room and fridge had been resolved. However, it was noted that there were several bottles of eye drops in the fridge on the first floor that were past their expiry date. The home has a contract with a clinical waste company for the disposal of medication. Staff were observed treating the individuals living in the home respectfully and the service users spoken to said that staff were ‘helpful’ and ‘generally good’. Vicarage Farm Nursing Home DS0000010962.V257360.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): 12, 13 and 15 Social activities are provided for the people living in the home. Maintaining contact with family and friends is encouraged. The meals in the home are good offering both choice and variety; however, specific cultural needs of service users are not always met. EVIDENCE: The home has an Activities Co-ordinator who works full time in the home. She works on the first floor in the mornings and on the ground floor in the afternoons. The manager said the Activities Co-ordinator has enrolled on a training course in Arts and Crafts to enhance her skills and enable her to do more with the service users. The manager also said that the home has plans to develop a sensory room in the home and that the Activities Co-ordinator was involved in some fundraising to assist with this. The activities programme for the home was displayed on notice boards and included activities such as singing, dancing, memory games, skittles, keep fit, arts and crafts. It was also noted that dates of religious festivals across a wide variety of faiths were also displayed around the home. It was noted that preferences regarding daily routines were recorded in the records viewed and incorporated into care plans. Visitors are welcomed in the home and the manager, staff and service users spoken to said that visitors were welcome at any time. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 13 The menus viewed were satisfactory and the meals provided varied and of good nutritional value. However, the manager of the home acknowledged that she had not yet been able to address the issue of satisfactorily providing culturally specific meals to service users. As mentioned earlier she said that she was looking at ways to address this issue. Vicarage Farm Nursing Home DS0000010962.V257360.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): 16 and 18 The home has a satisfactory complaints system with information available to service users, staff and visitors to the home. The home has adequate systems in place for the protection of service users from abuse. EVIDENCE: The home has a satisfactory complaints procedure in place that provides all of the relevant information for someone wishing to make a complaint. A detailed complaints record is maintained that is signed by the manager of the home. This record was viewed and was in order. The Commission for Social Care Inspection (CSCI) had received two anonymous complaints about the home since the last inspection. The first one of these had been investigated by the CSCI and the manager of the home had investigated the other. Both of these complaints had been unsubstantiated. The home has satisfactory procedures in place for the protection of service users and clear guidelines for staff regarding the action they should take if they witness or suspect abuse is taking place or if an allegation is made. This information was readily available in the home and followed. Protection of Vulnerable Adults training had taken place in the home two weeks prior to this inspection and the training programme for the home showed that very regular training updates of this kind take place for all staff in the home. Vicarage Farm Nursing Home DS0000010962.V257360.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): 19, 20, 21, 22, 25 and 26 The home is generally, safe, clean, comfortable and well maintained and provides appropriate facilities and equipment to ensure the safety and welfare of service users and allows them to remain as independent as possible. EVIDENCE: There were no noted maintenance issues at the time of the inspection and the décor and furnishings were satisfactory. An Environmental Health Officer had visited the home in May 2005 and the report showed that everything in the home was satisfactory. The home has a maintenance worker who carries out any minor repairs in the home and a record is maintained of the work carried out. The home has appropriate, comfortably furnished communal areas for service users on both floors. There are good sized lounge and dining areas and there is adequate space for service users to meet any visitors in private. An Occupational Therapy assessment of the whole building had been carried out since the last inspection. The report outlining any recommendations was Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 16 viewed. A recommendation had been made to provide two mechanical bathroom hoists, one on each floor, this had been actioned. A recommendation had also been made to convert one of the upstairs bathrooms into an assisted shower room. The manager said that this work had been approved and the paperwork relating to the approval of the work was viewed. The lighting and ventilation in the home were satisfactory. Fans are still in use on the first floor to improve ventilation. There had previously been problems with the home’s central heating system. When asked about this the manager acknowledged that there were still ongoing problems with the heating system in the home and that regular repairs were being carried out. The records viewed confirmed this. The home has appropriate laundry facilities and these were clean and tidy on the day of the inspection. The home was generally clean and tidy and there was no malodour in the home. Vicarage Farm Nursing Home DS0000010962.V257360.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): 27, 28, 29 and 30 The numbers and skill mix of the staff team was adequate and the recruitment process was satisfactory. Staff training was generally adequate, however mandatory training courses need to be kept up to date to ensure safe working practices and to maintain the welfare and safety of service users. EVIDENCE: The manager of the home said that there were no staff vacancies at the home at the time of the inspection. She said that there were plans to reduce the numbers of staff on each shift during the day from six to five members of staff. It is recommended that the organisation gives very careful consideration to any reduction in staffing to ensure that the home has adequate staffing to meet the needs of service users and to enable additional staff support when needed. The rotas viewed were satisfactory and there were adequate numbers of staff on duty on the day of the inspection. The manager said that nine members of care staff were in the process of completing their NVQ level two training and that one member of care staff was completing level three. Four other carers were in the process of completing their adaptation training. Staff employment records were viewed for three members of staff. These records contained all of the required information and were well organised and up to date. The administration officer for the home monitors staff records and chases up any outstanding documents. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 18 The home has a comprehensive training programme in place that is closely monitored by the manager of the home. Recent training dates had included COSHH training, Protection of Vulnerable Adults training and risk assessment training. The manager however acknowledged that there was a backlog in the provision of mandatory training courses such as food hygiene, fire safety and health and safety to ensure staff remain up to date in these areas. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The home is managed by an efficient and committed manager. Service users financial interests are safeguarded by the accounting systems in the home. The home has appropriate systems in place to ensure the health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager had completed her interview to become registered with the Commission for Social Care Inspection as Registered Manager for the home at the time of the inspection. She was just waiting for her references to come through for the process to be completed. The day before the inspection the manager said she had completed her induction for the Registered Manager’s Award and provided the paperwork relating to this as evidence. The financial records and monies kept for service users in the home were examined. These were up to date and in order and the amounts of money held in the home correlated with the amounts in the records viewed. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 20 Health and safety and maintenance records for the home were viewed. These were generally up to date and in order, however, there was not an up to date gas safety certificate for the home. As discussed earlier mandatory training for staff was not up to date at the time of the inspection. There were no fire doors propped open at the time of the inspection and the fire safety records for the home were up to date and in order. Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 2 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 3 X X X 3 X X 2 Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 22 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. 2. 3. Standard OP7 OP9 OP15 Regulation 17(3)(a) 13(2) 12(4)(b) Requirement Risk assessments for individual service users must be dated Any medication past it’s expiry date must be disposed of. Meals provided must meet the individual cultural needs of service users. (Timescale of 01/07/05 not complied with) Timescale for action 01/01/06 16/11/05 01/01/06 4. OP25 23(2)(c) 5. 6. OP30 OP38 18(1)(a) 13(4)(a) A more permanent solution must be found to remedy the problems with the heating system in the home All staff must receive regular updates of mandatory training An up to date gas safety certificate must be available for inspection. 01/02/05 01/03/06 01/01/06 Vicarage Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 23 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 Farm Nursing Home DS0000010962.V257360.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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