Inspection on 24/04/09 for Vicarage House

This inspection was carried out on 24th April 2009.

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

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 House 02/05/08

Vicarage House 09/05/07

Similar services:

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Snydale Care Home

Hawkhills

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The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Vicarage House 10 Church Street Ravensthorpe Dewsbury West Yorkshire WF13 3LA Lead Inspector Cheryl Stovin Key Unannounced Inspection 24th April 2009 10:30 DS0000069232.V375151.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Vicarage House DS0000069232.V375151.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) Plus Care Homes Limited Dean Mitchell Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Vicarage House DS0000069232.V375151.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 2nd May 2008 2. Date of last inspection Brief Description of the Service: Vicarage House provides personal care and accommodation for up to twenty older people. 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 £380 per week. 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.V375151.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 One Star. This means the people who use this service experience adequate quality outcomes. This report brings together evidence gathered during the Key Inspection of Vicarage House. This included a visit made to the home on 24th April 2009. A total of six hours were spent on the visit. During this visit we looked round the building looked at records and talked to people living and the home and to management and staff. In addition to the visit questionnaires were sent to people living at the home, staff and health care professionals to give them the opportunity to comment on their views as to the care provided in the home. Eight people living at the home, one health care professional and one member of staff responded. The comments received were positive and information received has been included in the main body of the report. The last inspection of the home was on 2nd May 2008 and no additional visits have been made. The purpose of the inspection is to make sure that people receive the care and support they need and that they and their families are satisfied with the service. An Annual Quality Assurance Assessment (AQAA) completed by the home was returned promptly and gave useful information. I would like to thank everybody for their warm welcome and assistance given during this inspection. What the service does well: There is a warm and welcoming atmosphere in the home and people said this was always the case. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 6 People said that they were satisfied with the standard of care and facilities provided and described their care as first class, they treat you well, its great and everybody is good to you. The home is clean, comfortable and well maintained. The garden is attractive and accessible. The staff recruitment procedures are thorough and safe. Staff are well trained and qualified and the comprehensive training programme makes sure staff skills and knowledge levels are kept up to date. Each person is treated as an individual. If people have concerns with their care, they or people close to them know how to complain. What has improved since the last inspection? What they could do better: Everybody living at the home has an individual plan of care. The care plans, however, do not contain sufficient detail to show how the care is actually be delivered. There is no suggestion that peoples needs are not being met, but the care plans should reflect how the care is to be given. This will make sure that everybody received support in a consistent way and in accordance with their preferences. All staff responsible for administering medication must receive appropriate training. This makes sure that medication is given safely. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 7 There are temporary management arrangement in the home and this should be resolved, this is to make sure that the home is run in the best interests of the people living there. All complaints received by the home must be recorded and a record kept of the investigation and of the outcome of the concerns raised. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Vicarage House DS0000069232.V375151.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 House DS0000069232.V375151.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before moving into the home to make sure that the home can fully meet their needs. EVIDENCE: People’s needs are fully assessed before they move into Vicarage House, this is to make sure that the home can meet their needs and that the facilities will be suitable for them. People are encouraged to visit the home before making a decision to move in. This gives them the opportunity to meet the staff and other people living there and to sample the daily routine at the home. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 10 Detailed information about the home and the services and facilities provided is given to everybody and a copy held in their rooms. People said that they had received sufficient information about the home before deciding to move in. Intermediate care is not provided in the home. Vicarage House DS0000069232.V375151.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all peoples support needs are recorded in their plan of care. EVIDENCE: The care records of six people living at the home were seen. Everybody has a care plan which contains details of peoples assessed support needs. The care plans seen did not contain sufficient detail as to what actions need to be taken to meet peoples specific needs. Examples of this are as follows. In one persons care plan it was stated promote independence, but nothing to say how and in what way. In another persons care plan it was recorded that they need assistance in most tasks and again no detail as to how the assistance is to be given. In another care plan it was recorded that they are at risk of Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 12 breaking down in the bottom are – observe. No detail was recorded as to what to do to prevent pressure sores and to promote good skin integrity. No information about peoples previous lifestyles and interests is recorded nor any information about family and friends and people that are important to them. This type of information gives the staff an understanding of the person as a whole and helps them to assist people to follow their interests and hobbies. The home is in the process of implementing a new system of care planning documentation which can easily incorporate the above comments. On the questionnaires we sent to the people who live at the home, everyone said that the staff listen and act on what they say, and all agreed that the staff treat them well. There is a lively, relaxed atmosphere at the home and people confirmed that the staff respect and promote their individuality and dignity at all times. One person made the additional comment: When I first heard that I was to be admitted to a residential home I cried for two days, however, the home has far exceeded my expectations. A Health care professional who returned a questionnaire made the following comments: Generally caring and helpful staff. Caring, friendly and treat clients as individuals. Any medication held in the home is securely stored, and Medication Administration Records were seen to be accurately completed. Any controlled drugs are appropriately held. All controlled drugs must be signed for when administered by two members of staff. The records show that there had at times been only one signature was recorded. Not all staff responsible for administering medication have received training and must do so. This is to make sure that medication is handled safely. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are offered some activities and are able to make their own choices about how they spend their time. EVIDENCE: On the day of the visit new furniture was being delivered and people were having to spend time in their own rooms. Staff were seen to be working hard to minimise the disruption. People said that usually they can choose where and with whom to spend their time. Visiting relatives said that they are always made welcome when they visit the home and are kept informed of important matters affecting their relative or friend. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 14 People said that they enjoy the meals provided at Vicarage House, describing the food as “very good food” and “well balanced, varied and nicely presented” and you have a choice, my needs have always been catered for. The main meal of the day is served at lunchtime. On the day of the visit everybody was having their meal in their rooms due to the dining area being unavailable. The lunch being served on the day of the visit was fish, chips and peas or baked haddock, followed by a choice of stewed apple and custard, ice cream, yoghurt or fresh fruit. The kitchen facilities have recently been inspected by Environmental Health Officers and awarded a four star rating, this means that the standard of kitchen hygiene has been assessed as ‘good’. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the complaints and adult protection procedures which the staff understand and put into practice. This makes sure that people living at the home are safe, however, not all complaints received are recorded. EVIDENCE: The home has a complaints procedure a copy of which is displayed and is also available in each bedroom. People who completed a questionnaire were aware of how to make a complaint if they were unhappy about anything in the home. A complaints log is held, however, not all complaints received are recorded. There was reference made to an outstanding complaint at the last inspection, but no record of this and of the resolution was recorded. The staff have received adult protection training and are aware of what to do if they suspect that an incident of abuse or poor practice has occurred. The home’s policies and procedures are up to date and the staff are aware of the procedures and guidance they contain. During the week of the visit a total of Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 16 17 safeguarding referrals regarding Vicarage House had been received by the local authority, these are in the process of being investigated. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25,26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe and clean environment which suits their needs. EVIDENCE: Vicarage House is situated in a residential area in the centre of Ravensthorpe with local shops and facilities within walking distance. Dewsbury town centre is easily reached by public transport. There are eighteen single bedrooms and one shared room. People said that they were satisfied with their rooms and the majority of people have brought Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 18 with them their personal possessions which makes the rooms look homely and comfortable. As previously stated, on the day of the visit new lounge and dining furniture was being delivered. In addition, the home was in the process of being redecorated throughout and new carpets are to be fitted when the decoration is completed. There is a pleasant, safe and accessible patio and garden area for people to enjoy in the warmer weather, A tour of the building showed that the home was clean and hygienic throughout, people confirmed that this was always the case. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s needs are met by a well trained and competent staff team, and are protected by the rigorous recruitment practices. EVIDENCE: There are sufficient staff on duty at all times of the day and night to assist people in their daily living activities and support them to take part in their chosen leisure pursuits. There are also enough domestic and catering staff employed to ensure the home is kept in good order and the kitchen and laundry function effectively. There are always three care staff on duty during day time hours and two waking night staff. Staff said that for the majority of the time there were enough people on duty to make sure that they can meet everybody’s needs. There is a commitment to staff training in the home and staff confirmed that they had been given sufficient training to make sure that they can meet the needs of the people living in the home. There is a programme of National Vocational Qualification (NVQ) and all staff are expected to achieve the award. This will make sure that care is given in a professional and consistent way. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 20 People living at the home said that the staff respond to their needs promptly and said all the staff were kind and caring. One person said: Time is the most important gift one can give which the staff at Vicarage House always give. The staff recruitment files of six recently appointed care workers were seen. All of the files contained CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) disclosures. Two written references, an application form and proof of identity were also in place. This makes sure that only suitable people are employed at the home. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately run with a temporary management structure in place, which means peoples interests are protected. EVIDENCE: At the time of the visit the home was being managed by the deputy manager and the owner of the home. It is anticipated that a permanent management structure will shortly be put into place. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 22 Financial procedures are in place to make sure that people’s money is handled safely. There is a commitment to health and safety and safe working practices in the home. All staff receive mandatory health and safety training with regular updates. Fire drills are carried out on a regular basis and all staff receive fire safety training. Certificates were seen which showed compliance with gas and electrical regulations. There is a formal quality assurance system in place to make sure that people are satisfied with the service provided. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 23 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 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 2 3 x 3 x x 3 Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 22 Requirement All concerns or complaints raised about the care of any person living at the home or on behalf of that person must recorded. This remains outstanding from the last inspection. Timescale of 30/05/08 not met. To make sure that peoples care and support needs are met the care plan must detail what actions need to be taken to meet the assessed needs. To make sure that peoples health care needs are fully met any person who is at risk of developing pressure sores is assessed by a person trained to do so. The appropriate care must be recorded in the persons plan of care. To make sure that medication is given safely all staff responsible must receive training in how medication is used. All controlled drugs administered to people must be signed for by DS0000069232.V375151.R01.S.doc Timescale for action 30/05/09 2 OP7 15 30/05/09 3 OP8 13 30/05/09 4 OP9 13 01/06/09 5 OP9 13 10/05/09 Vicarage House Version 5.2 Page 25 two people. The person giving the medication and a witness. 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 OP31 Good Practice Recommendations To make sure that the home is run in the best interests of the people living there suitable management arrangements should be confirmed. Vicarage House DS0000069232.V375151.R01.S.doc Version 5.2 Page 26 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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