Inspection on 02/05/08 for Vicarage House

This inspection was carried out on 2nd May 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 House 24/04/09

Vicarage House 09/05/07

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Vicarage House 10 Church Street Ravensthorpe Dewsbury West Yorkshire WF13 3LA Lead Inspector Mavis Pickard Key Unannounced Inspection 2nd May 2008 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 House DS0000069232.V363179.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 House DS0000069232.V363179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vicarage House Address 10 Church Street Ravensthorpe Dewsbury West Yorkshire WF13 3LA 01924 459585 01924 459060 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) Vitality Healthcare Limited. Vacant Post Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 20 Can accommodate one named service user over 65 years - category MD(E) 9th May 2007 2. 3. Date of last inspection Brief Description of the Service: Vicarage House provides personal care and accommodation for up to twenty older people. The service is owned by Vitality Healthcare Limited. The home located in the town centre of Ravensthorpe, near Dewsbury is close to shops and other amenities. Transport facilities are easily accessible. The home is arranged on two levels both accessed by a passenger lifts and a stair lift. The home has 18 single and 1 double room. The communal sitting and dining area is well used by all people who live at the home. A conservatory to the rear of the property leads out to raised flowerbeds and a pleasant seated area. At the time of this visit the fees to live at the home are £. Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. This unannounced visit started at 10:30 am and ended at 2:30 pm. There was the opportunity to speak to people living at the home as well as visitors, the acting manager and care staff. The care plan files of people living at the home were seen and included assessments care plans, daily and medical records and the record of activities. Staff records were also seen and included application forms, references, police checks and training records. A sample of people’s medications were checked and a look around the home was undertaken. Other information considered was the home’s returned Annual Quality Assurance documents and surveys that were returned to the Commission for Social Care Inspection. Many people had returned the home’s own surveys, which were in the main positive. A good number of people responded to our survey, and the feedback received was positive. We would like to thank people who live at the home and their relatives along with the acting manager and staff for their hospitality, patience and cooperation throughout the visit. What the service does well: People spoken with during this visit are confident that the care home can support them, this is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. Assessments tell the people working at the home all about people and the support they need. People’s health, personal and social care needs are in the main met by staff at the home, and each person has a detailed plan of care that the person, or someone close to them, has been involved in making. Each person is treated as an individual. If people have concerns with their care, they or people close to them know how to complain. People live in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Health, personal and social care needs are set out in individual plans of care which means that staff can see immediately how to support people at the home. The home’s medication policy and procedure’s are clear which means that people are protected. and are followed Staff now receive structured induction training when they commence. This means that staff are competent to perform their role. The recruitment processes have improved and now ensure the people living in the home are sufficiently protected by the home’s recruitment policy. The service is undertaking a general re-decorating and re-furbishment programme throughout the home. An improved garden area is almost completed that has provided raised flowerbeds and a new more gradual ramped area from the conservatory to the garden. This will give better access to the garden area for all people. 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. The summary of this inspection report can be made available in other formats on request. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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 House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 People living in the home experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit. People’s needs are assessed prior to them moving into the care home. Not all people returning to the home from hospital have their needs assessed before moving back into the home. EVIDENCE: The admission process was discussed with the manager of the home. Care records looked at contained evidence of a social services assessment and show that the assessor was confident that the service could meet the needs of people admitted. The acting manager told us about a person who lived at the home for several months who had recently returned to the home from a period in hospital. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 9 Although the acting manager said that they had assessed the person before agreeing that they return to the home, it was clear from our conversation that the person was admitted back to the home before the pressure relieving and moving and handling equipment required by them was available in the home. Concerns have been raised about this issue with CSCI and with the local Social Services Department, who are currently undertaking an investigation of the issues. The home does not provide intermediate care. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People living in the home experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit.People’s care needs are set out in a detailed care plan. People are treated with respect and they are safeguarded by clear medication policies. EVIDENCE: People who responded to the our survey said that their relative “always” or “ usually receive the care and support they need. The acting manager provided evidence from the home’s quality assurance surveys, this told us that in general people believed that their care and/or their relative’s needs are being met by the service. We spoke with two relatives during the visit who said that they have no concerns about the service provided, that their relative had lived at the home for a few years and they remained happy about their care. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 11 An individual’s right to choice, privacy and dignity is recorded in their care records and people were seen to be treated in a dignified and respectful manner by the staff on duty. The care records for two people were looked at. The records contained some good basic information. And there was sufficient detailed information to ensure the specific needs of each individual can be fully. The records looked at were up to date but there was no evidence of individuals or their relatives being involved in their plan of care. Community nurses spoken with told us that they have concerns that people were sometimes treated with creams or have dressings applied by the staff at the home which ideally should be dealt with by the community nursing service. Risk assessments were in place and people have assessments for nutrition and tissue viability (to measure the risk of developing a pressure sores) however we were told that a person returning from hospital who had a pressure area was taken back into the home before the necessary pressure relieving and moving and handling equipment was available in the home for their use. [Please refer to standard 1-6] Overall the standard of records kept in the home are adequate but staff providing care should make sure that they follow the procedures with reference to pressure relieving and mobility equipment. The home’s medication system was audited and the medication for two people were checked there were no concerns relating to medication. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People living in the home experience good outcomes in this area. We have made this judgement using a range of evidence including this visit. Generally people’s cultural, religious, social and recreational needs are being met, and they are supported to maintain contact with their family and friends. People living at the home have a varied and nutritious diet. EVIDENCE: People who responded to the homes and our surveys said there were “ always or “usually” activities arranged by the home. The interests of individuals are recorded in the care records. Planned activities and events are displayed on the home’s information board. Individual religious observance is respected by visits from a local priest and vicar, and people are supported to go out to church should they wish to do so. Visitors spoken to during this visit said that they are welcome to visit their relative whenever they wish. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 13 People are supported to manage their own finances if they wish and a locked drawer is provided in each person’s room for safekeeping. Individual rooms seen during a tour of the home showed people had personalised their rooms. People spoken with and those who responded to surveys told us that the meals are good and that they or their relative enjoyed their meals. We witnessed staff assisting people with their meals in a discreet and dignified way Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. At this visit people said that they are confident that the home will listen to any concerns raised. Individuals are protected from abuse. EVIDENCE: Everyone who responded to the survey said they knew who to speak to if they were not happy. Surveys received told us that people feel that they or their relative is safe and that people listen should they complain. There has been 1 concern received by CSCI since the previous visit, this is being investigated by Social Services, the outcome will be made available in the next report. All staff working in the home has received training in the protection of vulnerable adults and the acting manager knew what actions they should take should there be any allegations of abuse in the home. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a safe and well-maintained environment. The home is clean and people have comfortable rooms with their own processions around them. EVIDENCE: The home is clean and pleasantly furnished and decorated. The acting manager told us that the dining room/lounge is to be completely refurbished and to have new chairs and a new flat screen television. All surveys received said that the environment is good. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 16 Two bedrooms are presently being re-configured; when this work is completed both rooms will have en-suite facilities. Although some parts of the home are showing signs of general wear and tear the acting manager told us that there is a maintenance programme and that the home has a maintenance person who is getting to grips with a thorough redecoration programme. The home has a well-equipped laundry with hand washing facilities. During a tour of the premises and garden we saw that bedrooms were pleasant and bright and that people had personalised their rooms. The garden has new raised flowerbeds and the ramped access to the garden from the conservatory has been re-figured to give gentler slope providing access to the garden for everyone. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is enough staff on duty and they have received training to perform their roles. There is an appropriate and thorough recruitment programme. EVIDENCE: Staff are employed in sufficient numbers to meet the care needs of people living at Vicarage House. The people spoken with and surveys received made positive comments about staff. Two people spoken with during the visit said that staff are “lovely and helpful”. Comments received from the home’s quality assurance surveys and from our surveys say that care staff have the skills and experience to care for people properly. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 18 There are more than 50 of care staff that have received training to the [NVQ] National Vocational Qualification at level 2 or equivalent. The records of the two most recently employed people were checked. Both had a full employment history and showed that references and POVA first checks were received before staff started work. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run and managed by a person who is fit to be in charge and who makes sure that the home is run in the best interests of people who live there. People who live and work at the home are protected by the home’s health and safety procedures. EVIDENCE: There has been a change of manager since the previous inspection visit. The home’s acting manager Dean Mitchell is not yet the registered manager and is Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 20 presently awaiting his Criminal Records Bureau [CRB] to be returned so that he can go ahead with his application for registration. Mr Mitchell told us that is currently undertaking the NVQ level 4 in Care and the Registered Managers Award. In order to make sure they provide a good service, the home has a quality monitoring system in place. The results of the quality monitoring surveys were made available to us during the visit and were overall positive. Mr Mitchell told us that any returns that showed where improvements could be made would be actioned where possible. It is the role of the maintenance person to check fire alarms, smoke alarms and electrical items. All safety records clear, detailed and up to date. Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Vicarage House DS0000069232.V363179.R01.S.doc Version 5.2 Page 22 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 OP3 Regulation 12(1)(a) Requirement Provision must be made to provide necessary pressure relieving and moving and handling equipment where the person’s health and welfare show that this is necessary. Where a person requires such equipment it should be in place before the person is admitted or re-admitted to the home. All concerns or complaints raised about the care of any person living at the home or on behalf of that person must recorded. Timescale for action 30/05/08 2 OP16 22 30/05/08 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 House DS0000069232.V363179.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 House DS0000069232.V363179.R01.S.doc Version 5.2 Page 24 - 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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