Inspection on 14/07/05 for Vicarage House Residential Home

This inspection was carried out on 14th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Residential Home 17/04/09

Vicarage House Residential Home 08/06/07

Vicarage House Residential Home 18/07/06

Vicarage House Residential Home 17/02/06

Vicarage House Residential Home 08/11/04

Vicarage House Residential Home 07/09/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Vicarage House Residential Home 1 Honicknowle Lane Pennycross Plymouth, Devon PL2 3QR Lead Inspector Kim Fowler Announced 14th July 2005 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 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 Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Vicarage House Residential Home Address 1 Honicknowle Lane, Pennycross, Plymouth, Devon, PL2 3QR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 779050 01752 779050 Dr Pepper`s Care Corporation Limited Gaynor Braddon Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability over 65 years of age of places (32) Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/11/05 Brief Description of the Service: Vicarage House is a detached, two storey property situated in the residential area of Pennycross, Plymouth. The home is registered to Dr Pepper’s Care Corporation Ltd and the Directors are Dr and Mrs Pepper. The home is currently managed by Mrs Woodward together with the Registered Manager Ms Braddon. The home is registered to provide residential accommodation and personal care for a maximum of 32 older persons over the age of 65 who may also have a physical disability. The home has 26 rooms approved for single occupancy, 17 on the ground floor and 9 on the first floor. There are 3 rooms approved as doubles, two are on the ground floor and one the first floor. No bedrooms have en-suite toilet facilities. There is a chairlift which goes most of the way up the main staircase. There is a choice of communal areas on the ground floor and access to a garden area which is attractive and well used by Service users in the summer months. Smoking is permitted in designated areas only within this home. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 51/2 hours and was a planned Announced inspection. A full tour of the premises took place and staff and care records were inspected. The Registered Manager, Management team. 4 relatives and 19 of the 32 service users were spoken with during this inspection. The CSCI received 2 Relatives/Visitors comment cards and 2 Service users comment card. What the service does well: What has improved since the last inspection? What they could do better: The home is required to have pre-admission assessments for all service users ensuring that staff is aware of the needs of future service users. If bedrooms are fitted with door locks this will increase privacy. All staff should have Adult Protection training and have completed CRB’s and 2 references on file thus ensuring service user are protected from abuse. An agreed representative of the Registered Provider must undertake monthly visits to the care home to report in writing to the Registered Provider and the Commission. This will inform the Registered Provider and the Commission of the conduct of the care home. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 standard(s) 1/2/3/4/5 Information made available in the homes Statement of Purpose and Service Users Guide assist service users to make an informed choice of a care home. EVIDENCE: The homes Statement of Purpose is made available for all service user and visitors as required in the last inspection. There is a notice displayed on the homes notice board stating that this document is available and were. Case tracking provided evidence that all private service users have contracts. The contracts seen contain the statement of terms and conditions of the home. Service users who are funded by the Local Authority the homes has copies of the purchase agreements. Room numbers and fees are recorded onto the homes contracts. The homes pre-admission assessment was seen on some service user files, one file did not contain a pre-admission assessment. The home does gather information on individual service users to assist with the admission process. Each shift has a qualified first aider on duty. The home continues to encourage staff training to include manual handling, diabetes awareness, stroke management, pain management and the use of the lift and stair lift. The occupational therapist is available to all service users and risk assessments are in place. The management team informed the inspector that a new service user came for lunch several times before moving in. Evidence was seen on one service user care plan of trial visits recorded. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 9 Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 standard(s) 7/8/9/10/11 The home continues to provide good personal support for service users in the home. EVIDENCE: Case tracking provided evidence that recorded into service users care plans were that reviews had taken place. The home has produced a document were they are able to clearly record all reviews/updates dates and who carried out the review. Weight is now recorded into individual care plans. All service users have access to health care services. These include their own GP, community nursing services, chiropody care arranged by the home or their own if preferred, dental care from the flying dentist, a visiting optician or family members take the Service User to an optician of their choice, audiologist will visit on request or a hospital appointment arranged. Physiotherapy is available when needed and all health care appointments and visits are recorded into individual files. The homes accident book was seen and case tracking provided evidence that this information is also recorded into care plans. Plymouth City Council Occupational Therapist assessment had been carried out and the report was read during this inspection and the recommendation made will be carried out during the planned extension of the home. The home has a new controlled drug book that is a hard cover as required in the last full inspection. The records seen were clear and concise. Some errors on the controlled drug book Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 11 were seen and these were not signed. 2 service users self medicate and have a risk assessment in place. The home has a procedure for the administration of medication and uses the NOMAD monitored dosage system. Any staff who administers medication received both in-house training and training from the local pharmacist. The home has lockable storage space and the 2 service users who selfmedicating holds their medication in the storage facility. The agreement signed by service users wishing to self medicate was seen. All rooms are now single to aid privacy and the home has policies and procedures to promote the privacy and dignity of service users. All examinations are carried out in private. All toilets and bathrooms have appropriate locks. The homes staff was seen knocking on service users bedroom doors before being invited to enter. Service Users said they felt they were treated with every respect. A policy and procedure covering the care of the dying and sudden deaths has been produced. Information is held on service users files regarding their wishes about funeral arrangements. The home has a designated file to record all deaths and include information on were the service user died and if next of kin were informed. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 standard(s) 12/13/14/15 The service users in this home can be confident that the home will enable them to make decisions about their own lives. EVIDENCE: Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 13 The service users who were spoken with during this inspection felt that the staff supported and respected their individual preferences in lifestyles and daily routines. The home arranges regular activities which include bingo, exercise sessions and quizzes and a bingo session was held during the inspection. The home hires transport as and when needed. A monthly newsletter about what is going on in the home is produced and copied to every service user and this was seen as evidence during this inspection. The service users and visiting family confirmed that they are able to have visitors at any time and the home has a designated visitors book. During the last inspection there was some confusion when a care assistant informed a service user to have lunch in the dining room because the inspector was in the home rather than eating lunch in the bedroom while entertaining her visitor. This was discussed at a staff meeting to make staff aware that the inspector does not expect any changes to the usual routines of the home. Family and friends are encouraged to visit when they wish and the inspector spoke to 4 visitors during this inspection. The service users seen and spoken with during this inspection agreed that the home offers them choices and their preferences were respected. They thought that life in the home was usually relaxed and routines easy going. They felt able to get up and go to bed when they wanted and that there were no strict rules telling them what they could or couldn’t do. Most Service Users felt they had the freedom to do as they wish. The menus were sent with the pre-inspection questionnaire and they were varied and wholesome. The service users agreed that the food was good and they also had a choice if the main meal was not to their liking. 2 of the service users had their own fridges and the home caters for special diets. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 standard(s) 16/17/18 Service users can be confident that their complaints or concerns will be listened to and acted upon. EVIDENCE: The homes complaint procedure was seen and the home has a designated complaints book. Their was one complaint recorded and had the actions and outcome of this complaint was well documented. The complaint was regarding a request by a family of a service user and the outcomes were agreed and signed by both parties. The service users spoken with felt that they could talk to the staff if they had any concerns or complaints. The management team informed the inspector that postal vote were given to all service users and some took the opportunity to use them and others declined. No service users requested to go to the polling station on this occasion but the manager stated that the home would have taken any service user if required. The home has policies on whistle blowing, and restriction of liberty and restraint and the Devon Adult Protection Alerter Guide. None of the staff or management had completed the Plymouth Adult Protection course and the inspector recommended that all staff complete this course. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 standard(s) 19/20/21/22/23/24/25/26 Parts of the home continue to maintain a suitable environment for its stated purpose. EVIDENCE: Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 16 The home was well maintained and decorated. Any defects were recorded and repairs/replacement carried out as soon as possible and the home employ a outside contractor to deal with all repairs. The garden was safe, attractive and accessible by the service users. Communal space included several lounge areas and a dining room. The garden was accessible to everyone and seating was available. A requirement from the last inspection that a glass in the patio doors in the lounge was cracked and must be attended to as soon as possible had not been repaired. The owners of the home had written to the inspector stating that this would be repaired when the planned extension was carried out as this door would no longer be in place. All bathrooms and toilets are fitted with locks that are accessible form the outside by staff in an emergency. There are two assisted baths a fixed hoist and a bathroom with a shower available for service users. Throughout the building, it is evident that individual service users have been supplied with aids, adaptations and equipment to meet their individual needs. The premises are also fitted with hand and grab rails. The home has available an assessment carried out by the Plymouth City Council occupational therapist. All bedrooms were comfortably furnished and many were personalised with the service user’s own possessions. A requirement from the previous inspection for bedroom doors to have locks fitted has not been carried out. Some rooms have storage facilities for medication, money and valuables. The home also has a call bells system in place. A tour of all the bedrooms provided evidence that all have natural light and the halls, stairs and landings were well lit. All radiators have been guarded. Valves have been fitted to thermostatically regulate the temperature of hot water. The maintenance engineer spoken with during this inspection provides a full and comprehensive service including conducting checks and tests on Legionella. The home was found to be clean, hygienic and mainly free from offensive odours, however one room has an odour problem and the manager is in contact with the continence advisor to assist the service user. The laundry was seen and was suitable for its stated purpose. The home has produced an infection control policy and procedure as required and the staff have the use of a sluice room. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27/28/29/30 Staff training is supported and promoted enabling service users to receive the best possible service. EVIDENCE: The home provided the inspector with a copy of the duty rota printed off from the previous 4 week. The rota shows that at weekend there is only 3 staff on duty during most of the day. This would be insufficient in an evacuation procedure and staff is expected to carry out laundry and cooking during the evening. The home does employ ancillary staff and a cook. At present 7 out of the 25 staff hold an NVQ level 2 or above. There was a recruitment policy and procedure in place. Case tracking provided evidence that the 4 staff records seen did not have all the required documents. One domestic did not have any references on file. The pre-inspection questionnaire showed evidence that not all staff have a completed CRB and the home is required to send a list to the Commission. 13 of the homes staff are now qualified first aiders and the home has one on each shift. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31/32/33/34/35/36/37/38 The Management team of this home ensures that records are maintained. The staff have regular training and the service users spoken with are happy and their needs are met. EVIDENCE: The Registered Manager is due to go onto maternity leave in a few weeks and she plans to do the Registered Managers award on her return. The inspector has requested details of the management arrangement of the home in the Registered Managers absence. The Commission has not received regular Regulation26 visits from the Registered Provider since November 2004. The service users in the home have requested that the service users meeting are held every 3 months. Staff meetings are held and minutes recorded and the staff are ballot about any proposed changes. The Registered Provider, Dr Pepper, issues a Newsletter monthly and one was provided to the inspector on this visit. The home carries out a quality assurance questionnaire for the staff and service users. As recommended at the last inspection the questionnaires Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 19 are now sent to the health and social care professionals and other visitors to the home. The homes business plan is available and the inspector was provided with a summary. The service users money was seen and checked. The records and money seen was correct and well documented. The home has a safe and if there is a build up of money the home will pass this to service users families. The home is aware to contact the Care Manager to arrange Court of Protection if needed. The staff training is arranged regularly and the staff who are unable to attend are scheduled for a 1 to 1 session with the manager. The owner visits unannounced and the home now carries out regular supervision for all staff and some documented evidence was seen during this inspection. The records are generally well maintained, clear and easy to access via the homes computer. The records are securely held and service users are able to access them on request. The maintenance man employed on a contract bases was interviewed during this inspection. It was evidence from this interview that all health and safety requirements are carried out and checked. Staff had received fire training and fire test were carried out weekly. And environmental risk assessments are in place, as are manual handling assessments and associated training for staff. Staff had received training in food hygiene, manual handling and many were qualified first aiders. The boiler checks and gas appliances were regular serviced and checks for Legionella were carried out. The inspector saw the accident book and fire training log for staff. One service user had put a bench across a fire exit during the inspection and the manager removed this immediately. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 2 2 3 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 3 3 3 3 3 3 3 Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 21 NO Are there any outstanding requirements from the last inspection? 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. Standard 3 20 Regulation 14 23 Requirement All service users must have a pre-admission assessment on file. The cracked patio door must be repaired or replace as stated in the letter supplied to the Commission. This requirement has been carried over from the previous inspection. Bedroom doors must be lockable to preserve the privacy of Service Users. This requirement is carried over from a previous inspection All staff employed in the home must undertake a CRB check and the list sent to the Commission. This requirement is carried over from the last inspection. All staff employed must have references on file. The odour in one room should be removed. The Registered provider or representative must carry out Regulation 26 visits to the home and send them to the Commission. Timescale for action 31/12/05 31/12/05 3. 24 16 31/12/05 4. 29 19 30/09/05 5. 6. 7. 29 26 31 19 13 26 30/09/05 31/12/05 30/09/05 Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 22 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. 3. 4. 5. 6. Refer to Standard 7 9 18 27 31 38 Good Practice Recommendations Any changes or updates to care plans should be signed by the person making those changes. Any errors in the controlled drug book must be sign. All staff should complete the Adult Protection course. The number of staff on duty at weekends should be looked at for the safety of the service users. The home should inform the Commission of the management arrangement when the Registered Manager go on maternity leave. The homes staff should ensure that service users do not block fire exits. Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI Vicarage House Residential Home D52-D04 S3500 Vicarge House Residential Home V224222 140705 Stage 4.doc Version 1.40 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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