Inspection on 09/05/07 for Vicarage House

This inspection was carried out on 9th May 2007.

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 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 02/05/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Vicarage House 10 Church Street Ravensthorpe Dewsbury West Yorkshire WF13 3LA Lead Inspector Bronwynn Bennett Unannounced Inspection 9th May 09:10 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.V336540.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.V336540.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 Teresa Gillings Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Vicarage House DS0000069232.V336540.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) 6th September 2006 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, and the responsible person is Mrs V Sachdev. The home is located in Ravensthorpe, near Dewsbury and is close to shops and other amenities. Transport facilities are easily accessible. The home is on two levels, which are accessed via a passenger lift and a stair lift. Eighteen bedrooms are for single occupation. The communal lounge/dining area is well used by the residents throughout the day. The layout of this communal area provides for separate seating arrangements and two televisions are available. There is a conservatory at the rear of the property. The home is staffed twenty-four hours a day and there is an on-call system in operation. The provider informed the Commission for Social Care Inspection on 13/04/07 that the fees range from £335.24 to £358.80. There are additional charges for hairdressing. 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.V336540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit. The inspector arrived at the home at 9.10am and left at 5.15pm. During this visit the inspector spoke to people living at the home, visiting relatives, some of the staff and the home’s manager. The inspector read records relating to people living at the home and the staff, looked at how medication is given and carried out a tour of the building. Prior to this visit the Commission for Social Care Inspection sent questionnaires to people living at Vicarage House. Seven questionnaires were returned. There were nineteen people living at the home on the day of this visit. Surveys were sent to ten relatives, four GPs and six social workers. Seven relatives and three GPs responded. Other information used as part of the inspection process was a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: This is the first visit to the home since it was sold in March 2007. The service is owned by Vitality Healthcare Limited, and the responsible person is Mrs V Sachdev. The home provides a relaxed and homely environment for people to live. People living at the home are cared for by the staff who respect their privacy and dignity. No one moves into the home without having their care needs assessed. Five people that responded to the survey said they received enough information about the care home prior top moving in. 75 of the staff have achieved NVQ level 2 or above in care. There were many positive comments received from people who use the service. One person commented that everything at the home was first class. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Vicarage House DS0000069232.V336540.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.V336540.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): 3. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People’s needs are assessed prior to them moving into the care home. EVIDENCE: The admission process was discussed with the manager of the home. The care records looked at contained evidence of a social services assessment. Five people that responded to the survey said they had received enough information about this home before they decided to move in. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 9 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. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. Not all health, personal and social care needs are set out in the individuals’ plan of care which means there is a risk of people’s health care needs not being fully met. The home’s medication policy and procedure does not sufficiently protect people living in the home. Generally people are treated with dignity, respect and privacy. EVIDENCE: Four people who responded to the survey said that they “always” receive the care and support they need. Two said they “usually” and one said they “sometimes” receive the care and support they need. Three relatives survey’s said the home “always” meets the needs of their relative and two people said the home “usually” meets their relatives needs. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 10 Three relatives were spoken to during this visit. All said that the staff are caring and offer a good level of care to their relative. Three GPs who responded to the survey said they were able to see their patients in private and that the staff had a clear understanding of the care needs of people who live at Vicarage House. The home offers people a calm, friendly and relaxed environment and the staff interact well with everyone at the home. An individual’s right to choice, privacy and dignity was recorded in their care records and people were noted to be treated in a dignified and respectful manner by the staff. The care records for three people were looked at. All the records contained some good basic information. However, there was insufficient detailed information to ensure the specific needs of each individual can be fully met. All care plans should be person centred and specify the assistance that is required by each individual. These issues were discussed with the manager who agreed to take action in this matter. 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. Again these issues were discussed with the manager. One daily record showed that the staff were treating areas of sore skin with an application of cream. However, there was no mention of such treatment in the care records looked at. This is not acceptable. Information must be available to show what areas are being treated along with a detailed care plan that gives clear information to staff. In addition, the care plan must be regularly reviewed to check the plan is working. Where other professionals are involved for example, a district nurse, a care plan must still be in place to direct the staff of the required actions that must be taken between visits by such professionals. There were risk assessments in place for the identified risks to individuals, but these assessments did not give sufficient detail for how the risk should be managed. Risk assessments were in place and people have assessments for nutrition and tissue viability (to measure the risk of developing a pressure sores) and the weights of individuals are recorded. However, through discussion with the manager there was some concern as to the accuracy of the assessments. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 11 Records did not contain the specific detail in how to move each individual, for example from the bed to a chair. This must be addressed to ensure the safety of the people being moved and the staff. The people who complete this sort of assessment require sufficient training to ensure such records are accurate. The overall standard of the records kept by the home does not meet the required standard. Care records must give the staff give information of the care and attention required by each individual. The home’s medication system was audited and the medication for three service users was checked. Two of the medications could not be fully reconciled with the records kept. These issues were discussed with the manager who agreed to take immediate action in the matter. Vicarage House DS0000069232.V336540.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 and 15. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a 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 are able to exercise choice and control over their lives. The home provides the people living at the home with a varied and nutritious diet. EVIDENCE: The home has taken action since the last visit by the CSCI and the activities provided at the home has improved. Six people who responded to the survey said there were “usually” activities arranged by the home and one person said there was “always” activity available in the home that they are able to take part in. A relative commented that the home provided a good range of activities and interests for people living at the home. The interests of individuals was recorded in the care records. Planned activities and events are displayed on the home’s information board. During this visit most people were enjoying a movement to music class. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 13 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. 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. The home offers a four weekly menu and offers a choice to the main meal on request. Meals offered are displayed and the cook talks to people on a daily basis regarding their choice of food. People spoken to during this visit said they enjoyed the food offered by the home. Six people who responded to the survey said they “usually” enjoyed the meals, and one responded that they “always” enjoyed their meals at the home. Vicarage House DS0000069232.V336540.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 and 18. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. People who live at home and their relatives are confident their complaints will be listened to and acted upon. Individuals are protected from abuse. EVIDENCE: Everyone who responded to the survey said they knew who to speak to if they were not happy. Six people said in the survey that they knew how to make a complaint, and one person did not know how to do so. Three relatives visiting the home during this visit said they would feel confident in raising a concern or making a complaint. There have been no concerns or complaints made to the home since the last visit by the CSCI. All staff working in the home has received training in the protection of vulnerable adults and the staff spoken to during this visit had a good understanding of necessary actions that must be taken should there be any allegations of abuse in the home. Vicarage House DS0000069232.V336540.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 and 26. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. Generally people live in a safe and well-maintained environment. The home is generally clean and people have comfortable rooms with their own processions around them. EVIDENCE: During this visit the home was noted to be clean and odour free. Five surveys received from people living at the home said the home is “always” fresh and clean, and two people said the home is “usually” fresh and clean. One relative that responded to the survey said that their relative had a “nice, clean bedroom”. Other comments referred to the home being in need of redecorating and replacement furniture. These comments were passed to the manager at the time of this visit. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 16 There are areas of the home that are showing signs of general wear and tear and in need of repair and maintenance. The home does have a sluicing facility to clean commodes, etc., but this is in need of updating to meet the current needs of people living at the home. These areas also require fitting with suitable hand washing facilities in order to meet infection control standards and prevent communicable diseases. The manager said that a maintenance person has recently been appointed and will carry out the necessary works in the home. It is a recommendation of this report that the home develops an ongoing programme of renewal and maintenance with the appropriate records kept. The home has improved the laundry facilities and this area is now equipped with suitable hand washing facilities. There have been some improvements made to the home. Locks have been fitted to everyone’s door to provide greater privacy and a bedroom has been redecorated. The manager has taken action and responded to issues raised at the last visit by the CSCI and all the home’s bedding and towels have been replaced. In addition individuals beds are being replaced. The inspector accepts that the home has recently been taken over by a new provider and that time needs to be allowed to identify and carry out the improvements required at the home. Vicarage House DS0000069232.V336540.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 and 30. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. There are enough staff on duty and they have received some training. However the staff must receive structured induction training when they commence so they are competent to do their jobs. The recruitment processes must improve to ensure the people living in the home are sufficiently protected by the home’s recruitment policy. EVIDENCE: Staff are employed in sufficient numbers to meet the care needs of people living at Vicarage House. The people living at Vicarage House spoken to during this visit made positive comments about the staff, as did the relatives. One person commented in the survey that that their relative was well looked after and generally the comments received from the surveys indicate that the care staff have the skills and experience to care for people properly. The information received by the CSCI states that there is 75 of the staff who have achieved NVQ level 2 in Care or above qualification. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 18 Three staff records were looked at. None of the records held a full employment history. This was discussed at the time with the manager who agreed to take immediate action in the matter. The staff undertake the homes basic induction training. However, there are currently no systems in place for staff to receive training that meets “Skills for Care” induction standards for new staff. (Skills for Care is the national training organisation). The manager said she was working towards addressing this matter. The staff working in the care home have completed some of the mandatory training, such as food hygiene, how to move people safely, and fire safety, and additional training is planned for the staff. Vicarage House DS0000069232.V336540.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 and 38. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit. The home is run and managed by a person who is fit to be in charge. Generally the home is run in the best interests of people who use the service. The financial interests of people living are safeguarded. Greater care must be taken to ensure the health and welfare of everyone is promoted and protected. EVIDENCE: The home manager is Mrs Teresa Gillings is registered with the CSCI. She has achieved NVQ level 4 in care and is awaiting the certificate for the Registered Managers Award. The home was sold in March 2007. The service is owned by Vitality Healthcare Limited, and the responsible person is Mrs V Sachdev. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 20 During this visit relatives, staff and people living at the home made positive comments about Mrs Gillings’ ability to run the care home. In order to make sure they provide a good service, the home has a quality monitoring system in place. The manager said that she has held one meeting for people living at the home and is hoping to continue this on a regular basis. In addition there are regular staff meetings. Questionnaires are sent to individuals and their relatives. The results from quality monitoring are discussed at residents meeting. However it was discussed that such information should be published and made available in the home. Three individual finances were checked. These records were correct. People are supported to handle their own finances should they wish to do so and locked facilities are available in individual rooms. The fire records were checked and gaps were seen in the recording for the testing of the homes fire alarm system and emergency lighting. This is not acceptable. The manager agreed to take action and ensure fire testing in the home is carried out on a weekly basis to ensure the systems are working properly and people are protected. Vicarage House DS0000069232.V336540.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 X X 3 X X X 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 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NA STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 04/07/07 2. OP8 12,13 and 14 The care plan must show how the individual’s needs, in relation to their health and welfare will be met by the home. The care plan must be made available to the individual and kept under review. 04/07/07 Where a risk has been identified the appropriate risk assessment must be completed and kept in the individual’s care records. These assessments may require an additional care plan for example, nutrition, tissue viability and where there is a risk of falls or specific manual handling needs. 3. OP9 13.2 4. OP30 18 5. OP38 23 The registered person shall make 06/06/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. All new staff must receive 04/07/07 structured induction training that meets “Skills for care” standards. The registered person must take 16/05/07 DS0000069232.V336540.R01.S.doc Version 5.2 Page 23 Vicarage House adequate precautions against the risk of fire and the testing of the homes fire alarm and emergency lighting must be tested on a weekly basis. 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. 2. Refer to Standard OP19 OP26 Good Practice Recommendations There should be an ongoing plan of maintenance for the home. The sluicing facilities should be improved to ensure they meet the current needs of people living at the home. Vicarage House DS0000069232.V336540.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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.V336540.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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