Inspection on 08/06/05 for Vicarage Road (62)

This inspection was carried out on 8th June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vicarage Road (62) 04/08/09

Vicarage Road (62) 06/08/07

Vicarage Road (62) 13/12/05

Vicarage Road (62) 27/01/05

Vicarage Road (62) 23/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Vicarage Road (62) 62 Vicarage Road Buntingford Herts SG9 9BA Lead Inspector Angela Dalton Unannounced 8 June 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Vicarage Road (62) Address 62 Vicarage Road, Buntingford, Herts, SG9 9BA 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) 01763 273191 Granta Housing Society Limited Kim Taylor CRH Care Home 4 Category(ies) of LD-4, LD(E)-4 registration, with number of places Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27 January 2005 Brief Description of the Service: Vicarage Road is part of Granta Housing Association Ltd. The home is situated at the end of a cul-de-sac in a quiet residential area of Buntingford and within walking distance of the town centre. The ground floor consists of a lounge with dining area, a kitchen with breakfast area, a utility room, one single bedroom and a W.C. A stair lift has been installed. The first floor comprises three single bedrooms, bathroom and toilet. There is a small office that is also used as the staff sleeping in room. To the front is a large driveway to the home where the home’s vehicle is parked and a small well tended garden. There is a larger garden to the rear of the property. The home is registered for 4 service users with a learning disability including those over 65 years of age. Vicarage Road was first registered 2nd September 1993 under the Registered Homes Act 1984. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one Inspector on 8th June 2005 between 10.30am and 4.20pm. Vicarage Road is home to four service users and truly achieves a homely environment and atmosphere. The care provided is of a high standard. Service users are encouraged to be independent and assessed risks are taken as part of this process. Disappointingly, the majority of previously made requirements and recommendations remain outstanding. Some further requirements have been made regarding the supply of hot water and issues relating to medication. Despite this the care aspect of the inspection was positive. What the service does well: What has improved since the last inspection? Medication that is no longer in use is not stored at the home. A training schedule is in place to ensure that all staff receive regular updates to assist in meeting service users’ needs. Quotes to replace the domestic bathroom to a walk in shower are currently being secured. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 6 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. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Service users are dependent upon others to receive information about the home. Individual needs are regularly reviewed. EVIDENCE: The Statement of Purpose is in place but is not in a format that is appropriate to meet service users needs. The previous recommendation to update the information to include reference to the smoking policy remains unmet. The service users who live at the home have lived at Vicarage Road for some time. An assessment process is available if needed in the future. All service users have a copy of their contract in their individual file. Needs are assessed on a regular basis and recorded within the care plan. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Service users’ current needs are reflected in the care plan. Service users participate fully in planning their care requirements and provision. EVIDENCE: Care plans are securely stored in the office. There was evidence that the service users are involved in the regular review of their needs and this is recorded in individual care plans. House meetings are an opportunity for the group to discuss any concerns that they may have. One service user went for his regular visit to the local coffee shop during the inspection and the care plan demonstrated that any potential risks had been assessed and managed accordingly. The acting manager and staff team are in the process of reviewing risk assessments to ensure their appropriateness. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Individual preferences regarding meal choices and activities are observed. EVIDENCE: A menu is available in the kitchen which all service users contribute to. Due to the small number of service users living at Vicarage Road individual preferences and requirements are catered for. One service user was proud of their dietary regime, which had resulted in lower cholesterol levels. The staff team are currently exploring information about diabetes to better meet a service user’s needs. The age of service users is recognised and activities are tailored accordingly. A member of staff is employed to co-ordinate activities alongside their role as care worker. A record of activities is kept to illustrate that activities occur within the community and at home. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Service users are not protected by safe recording, handling and administration of medication. Individual service users funeral wishes are recorded. EVIDENCE: Service users have recorded their funeral wishes in their care plan to ensure that staff are aware of their requirements. Staff within the home liaise with other professionals and health needs of service users are accommodated. Medication issues have resulted in a Requirement being made. Medication must not be stored in the domestic refrigerator – a cream requiring refrigeration was seen being stored alongside food products. Copies of prescriptions must be kept in the home as this acts as a receipt that medication has been received. Amounts of PRN medication (Diazepam) were not carried forward on Medication Administration Record Sheets (MAR) to enable accurate stock records to be kept. Storage temperatures were not recorded to prevent medication from deteriorating in quality. Medication signed for must reflect that medication has been given to prevent under or over medication. Service users must be prescribed any medication they are given with appropriate records in place. No homely remedies policy was in place to reflect that service users could take Paracetamol. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home does not follow a comprehensive complaints procedure. EVIDENCE: The complaints process does not illustrate how complaints are investigated and concluded. Although complaints that are recorded are historical in origin there is no format for complaints to be explored and the route to the outcome is not noted. A recommendation has been made. A copy of Hertfordshire County Council’s Adult Protection procedure is kept in the home and staff have an awareness of the policy. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 Infection control within the home is compromised. Personal care needs are affected by the bathing provision within the home. EVIDENCE: The home is reflective of the tastes of the service users. It was clean and odour free. On the day of inspection there was no hot water available in the bathroom. The supply in the kitchen was reduced to a trickle. Staff and service users cannot wash their hands in hot water after visiting the toilet. The bath cannot be filled but the shower was reported to work. Tiles are broken on the wall but once a shower is fitted this issue will be addressed. This problem must be rectified and a Requirement has been made. The bath is domestic in style and is unsuitable for some of the service users due to mobility constraints. Requirements were made in the previous 2 inspection reports for the bath to be reprovided with a shower. As yet there is not a date for commencement of work to refurbish the bathroom. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard 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 Staff are aware of their roles, have access to training and supervision to enable a high standard of care to be delivered. Service users are not protected by the home’s recruitment policies. EVIDENCE: The registered manager is currently on sick leave and an acting manager from within the staff team has been appointed. One service user is currently in hospital and the staff levels are appropriate to meet service users’ needs. Staff personnel files did not have the required documentation in place. A Requirement has been again made to ensure that missing evidence is put in place. Supervision is taking place and the acting manager is putting together a supervision schedule to ensure that it occurs six times each year. Staff are working towards NVQ qualifications and the Acting Manager is due to enrol upon the Registered Managers’ Award. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42,43 The registered manager is currently on long term sick leave, the acting manager was promoted within the staff team. The health and safety of service users is compromised. EVIDENCE: The home has a quality assurance process (QUARTZ) in which the views of service users, staff and visitors to the home are sought. The acting manager is discussing with service users and staff how to make the results of the annual audit more accessible. Records were kept in good order (with exception to those referred to earlier). The inspector examined fire records, accident records, training, complaints and medication records. As discussed earlier the health and safety of service users is affected by the lack of hot water. Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 2 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Vicarage Road (62) Score 3 3 1 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 17 YES 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. Standard YA20 Regulation 13(2) Requirement Medication must not be stored in the domestic refrigerator. Copies of prescriptions must be kept in the home. Amounts of PRN medication (Diazepam) must be carried forward on Medication Administration Record Sheets (MAR). Medication storage temperatures must be recorded. Medication signed for must reflect medication has been given to prevent under or over medication. A homely remedies policy must be in place if non prescribed medication is given. This is to be signed by the GP or Pharmacist. Hot water must be available to enable service users and staff to wash and bathe. The fact that the bath was not suitable for service users needs has been identified at the two previous inspections. A commencement date for the refurbishment of the bathroom is required. All staff files must contain a copy of a birth certificate and Timescale for action 20/06/05 2. 3. YA27 YA42 YA29 23(2)(c)& (j) 23(2)(n) 20/06/05 30/06/05 4. YA34 17(1)(a) 19(1)(a) 30/06/05 Page 18 Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Schedule 2 Schedule 4 5. passport. Two written references must also be in place. THIS REQUIREMENT WAS MADE AT THE PREVIOUS INSPECTION 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 YA1 Good Practice Recommendations The Statement of Purpose should be reviewed to ensure it is service user friendly in a format that can be understood. The homes smoking policy should be incorporated and the Commissions details updated. A record of complaints investigation and how the conclusion was reached should be kept. 2. YA22 Vicarage Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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 Road (62) I52 s19603 Vicarage Road v230246 080605 Stage 4.doc Version 1.30 Page 20 - 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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