Inspection on 16/12/09 for Chapel View Nursing Home

This is the latest available inspection report for this service, carried out on 16th December 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chapel View Nursing Home 29/01/08

Chapel View Nursing Home 12/09/06

Chapel View Nursing Home 12/10/05

Chapel View Nursing Home 31/05/05

Chapel View Nursing Home 04/03/05

Chapel View Nursing Home 06/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Key inspection report Care homes for older people Name: Address: Chapel View Nursing Home Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ivan Barker     Date: 1 6 1 2 2 0 0 9 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 26 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. 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 Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Chapel View Nursing Home Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN 01226388181 01226380270 chapel.view@fshc.co.uk None Chapelfield View Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 39 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Persons accommodated shall be aged 60 years and above. There are 19 beds registered for nursing (N) and 20 for personal care (PC). Date of last inspection Brief description of the care home Chapel View is owned by Four Seasons Healthcare Limited. The home provides nursing and personal care and accommodation to thirty-nine older people. The home occupies a central position in the village of Mapplewell in Barnsley, close to shops, pubs, the post office and other local amenities. The home is a two-storey building. There are thirty-five single bedrooms and two double bedrooms. There is a Care Homes for Older People Page 4 of 26 Over 65 39 0 2 1 0 1 2 0 0 9 Brief description of the care home passenger lift. The home has a garden area that was well maintained and accessible. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: A number of the National Minimum Standards were examined at this inspection (with emphasis on the key standards), and the previous requirements. The persons present at this inspection were: Mr S Shires manager. Mr M Paul deputy manager. Within this site visit, which occurred over a 5 hour period, we examined requirements relating to the previous inspection. We toured the building, case tracked 3 people (case tracked means looking at the care and service provided to specific people living at the home; checking records relating to their health and welfare; by talking to the specific people; viewing their personal accommodation as well as communal living areas). Care Homes for Older People Page 6 of 26 We spoke with other people, relatives and also staff and examined assessments, care plans, risk assessments, menus, complaints files, staff records and quality monitoring documents. The history of the service was examined prior to the site visit. This included the AQAA (Annual Quality Assurance Assessment), a self assessment document, telephone contacts, letters and notifications. Care Homes for Older People Page 7 of 26 What the care home does well: Peoples needs were known to the service prior to admission. The 2 assessments ensured that the service had sufficient information to assess if the service was able to meet the persons needs. Accurate care plans will contribute to the delivery of care. People and relatives were satisfied with the care. The opinions of people and relatives and professionals were obtained. the following was stated. The care is great. I would come here. They (staff) look after them (people) brilliantly. We have seen marked improvement over the past few months. We do lots of things. The girl comes to talk to us about what we would like to do. Its very busy here. The meals are very good here. Yes they give us what we like. He likes a big breakfast and a small dinner, and this is what they give him. No we dont know whats for lunch, but its always nice. The staff are wonderful. The staff are really good/really nice. Things have really improved since the new manager came into post. Activities were organised and people were able to exercise their rights of choice regarding meals. This provided stimulation and enhanced their quality of life. There was evidence that complaints were taken seriously and acted upon. This should provide confidence that when complaints are raised that the service addresses any shortfalls in care or service provision. People lived in a service that had been maintained to a good standard to provide a safe, well maintained and homely environment. Care Homes for Older People Page 8 of 26 The manager was able to provide evidence that staff had received all necessary training which would reflect on the quality of care being delivered to the people. The staff recruitment process provided protection for the people. There was an experienced management team in place and clearly the management had improved since October 2009. Both of which contributed to the effective organisation and operation of the service. What has improved since the last inspection? What they could do better: 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. Care Homes for Older People Page 9 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were known to the service prior to admission. The 2 assessments ensured that the service had sufficient information to assess if the service was able to meet the persons needs. Evidence: On examination of 3 care plans it was established that assessments did occur prior to the admission of any person into the service. The manager advised that the care management assessments were faxed through to the service. On receipt of the information the manager undertook his own assessment using the Care and Health Assessment Profile (CHAP), which was a comprehensive assessment tool produced by the company. These assessments assisted in providing a considerable amount of information for the staff to decide if the service could meet the persons needs. It also provided sufficient Care Homes for Older People Page 11 of 26 Evidence: information for care plans to be drawn up. The manager advised that intermediate care was not provided within the service. Care Homes for Older People Page 12 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate care plans will contribute to the delivery of care. People and relatives were satisfied with the care. Evidence: On examination of the care plans from 3 people, it was established that the plans were up to date. However 1 plan had a monthly evaluation missing. This was several months prior to the date of this inspection. The manager advised that systems had been introduced so that members of staff signed that the care plans had now been evaluated on a monthly basis. We were shown this evidence which indicated that over the last few months, all care plans had been evaluated. There were daily entries within the care plans, which were examined. Comprehensive risk assessments were included within the care plans and included moving and handling, nutrition, skin integrity and other risk factors. There was also fluid balance charts and safety records within the rooms where people Care Homes for Older People Page 13 of 26 Evidence: were being nursed in bed because of their frail condition. On examination of these records, these were found to be up to date and they stated what time the person was given a drink or when a safe check was undertaken. Whilst touring the building it was observed that many people were in their frail condition and in bed. All the people who were observed to be in bed appeared to be comfortable and well cared for. Also whilst touring the building, we opened an external fire door which set off an alarm. All staff from both floors responded immediately to the sound of the alarm. This was an excellent response. The opinions of people and relatives and professionals were obtained. The care is great. I would come here. They (staff) look after them (people) brilliantly. We have seen marked improvement over the past few months. The storage, ordering, administration and disposal of medication was discussed with the manager. The procedures explained by the manager were satisfactory. On examination of the Medication Administration Records, the records were found to be fully completed. The medication trolley was chained to the wall in the care station situated on the corridor. It is best practice to have the medication trolley secured within a room, however it is accepted that storage is limited within the service. The manager agreed to re-examine the storage areas and look to relocating the trolley. The metal cupboard containing the controllled drugs was fastened to the wall with screws. The cupboard should be dead bolted to the wall to meet the required standard of security for controlled drugs. The manager identied that he would ask the maintainence man to act on this as a mattter of urgency. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities were organised and people were able to exercise their rights of choice regarding meals. This provided stimulation and enhanced their quality of life. Evidence: The manager advised that there was a Personal Activities Leader (PAL). This individual was responsible for organising the activities, outings etc. We were able to speak with the PAL, who was a very enthusiastic individual who was able to produce evidence that games, singalongs and outings were undertaken on a regular basis. On discussing activities with the people and relatives we receive the following comments: We do lots of things. The girl comes to talk to us about what we would like to do. Its very busy here. Regarding the meals, the manager advised that people were given a choice during the Care Homes for Older People Page 15 of 26 Evidence: meal time. We observed the meals being served and did observed that people were given a choice. The manager identified that the people were previously asked about their choice the day before and some individuals have forgotten what they ordered when it came to lunch time the next day. It was discussed that it may be more beneficial to ask the people doing breakfast rather than operating the over catering method currently in use to ensure that all the people had a choice. The use of menus or a menu board was discussed, so that people were aware what choices were on offer before the actual meal. The manager agreed that the use of a menu board would be beneficial and identified that this would be provided. At approximately 11 am it was observed that one person was alone in the dining room, eating his lunch. On discussing this fact with the staff, we were advised that the person was having an early lunch because he was going down to the market. We spoke with the gentleman and he confirmed that he was having an early lunch because who was eager to get down to the market. Clearly this was good that the care staff and kitchen staff had ensured that this gentleman had his meal when he required it. On discussing the meals with the people and relatives we received the following comments: The meals are very good here. Yes they give us what we like. He likes a big breakfast and a small dinner, and this is what they give him. No we dont know whats for lunch, but its always nice. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was evidence that complaints were taken seriously and acted upon. This should provide confidence that when complaints are raised that the service addresses any shortfalls in care or service provision. Evidence: The complaints procedure was available within the Service User Guide. A copy of the procedure was also on display. On discussing complaints with the manager he produced a complaints file. Within the file it showed that written complaints and the action taken were recorded. It detailed when the complaint had been raised but did not provide evidence that a complaint had been resolved within the expected 28 day period. The manager agreed that any complaints raised after today would be recorded correctly and have the completion date included. There were no complaints recorded in the complaints file since the appointment of the new manager. Regarding Safeguarding Adults, the service had policies and procedures which were available to staff. Staff had undertaken safeguarding adult training and the manager was able to evidence this by showing us the training records. Care Homes for Older People Page 17 of 26 Evidence: There was currently an investigation into allegations relating to safeguarding adults being undertaken by the Local Authority. The manager was working closely with various leads within safeguarding. Care Homes for Older People Page 18 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 lived in a service that had been maintained to a good standard to provide a safe, well maintained and homely environment. Evidence: On touring the building, it was observed that the service was decorated and furnished to a good standard, with only minor areas requiring repair/redecoration. Room 34 had damage to the ensuite door and Room 32 which was empty, was in need of redecoration. We were advised that the room would be redecorated before a new person was admitted into this room. Many of the peoples rooms had been personalised and contained photographs, personal belongings and some items of furniture which the individual or family had provided. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager was able to provide evidence that staff had received all necessary training which would reflect on the quality of care being delivered to the people. The staff recruitment process provided protection for the people. Evidence: On examination of the staff rotas and examination of staff on duty, the following was established. AM shift: 1 qualified nurse 1 senior carer 4 care staff. PM shift: 1 qualified nurse 1 senior carer 4 care staff. Night Shift: 1 qualified nurse and 3 care staff. Plus: The manager, administrator, personal activities leader, domestics, kitchen staff, laundry staff and maintenance man. Caring for a present occupancy of 31 people. A full assessment of the dependency levels of the people was not undertaken and Care Homes for Older People Page 20 of 26 Evidence: compared with the indicated staffing levels. On examination of 3 staff files, these were found to contain all the required documentation, including the Criminal Records Bureau and Protection Of Vulnerable Adults checks. We observed evidence that there had been some work undertaken on improving the organisation of the staff files. Some of the staff files were loose pieces of paper in a folder and others were organised in files with dividers and were easier reference. The manager advised that he had started to reorganise the files and was yet to finish the exercise. On examination of the staff training records, we examined both the training matrix and the staff training files. These indicated that staff had received training in moving and handling, fire and other clinical training. Also training had been planned for the following 12 months. The comments from people and relatives were: The staff are wonderful. The staff are really good/really nice. Things have really improved since the new manager came into post. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was an experienced management team in place and clearly the management had improved since October 2009. Both of which contributed to the effective organisation and operation of the service. Evidence: There was a manager in post, however he was not the registered manager. He advised us that he intended to make application to the Commission for registration. He had been in post since 1 October 2009 and had clearly implemented several improvements in the care and service provision, since his appointment, which had been observed by the people, relatives and us. He identified that he had several years experience in management and was committed to continue to improve Chapel View. Regarding Quality Assurance, we were shown evidence that there was quality monitoring within several areas of care and service provision. These were according to company policy. Care Homes for Older People Page 22 of 26 Evidence: Staff had received supervision, since October 2009. This had been implemented by the new manager. Further supervision sessions were planned for the following 12 months. The service had a credit and debit system regarding personal monies, which they held for safekeeping either in the bank or in their safe within the service. Regulation 26 documentation, which were records of the registered persons monthly visits were up-to-date. These documents were stored within the computer system and were easy to access. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc had been received by the Care Quality Commission. The information showed that appropriate action had been taken. The information contained in the AQAA confirmed that all the health and safety and maintenance had been undertaken. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The storage of medication needs to meet the minimum requirements. To ensure that controlled drugs are stored securely. 16/01/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 31 A registered manager should be managing the service. Care Homes for Older People Page 25 of 26 Helpline: 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. Care Homes for Older People Page 26 of 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!