Inspection on 22/07/05 for The Chace

This inspection was carried out on 22nd 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Chace 30/04/07

The Chace 14/02/06

The Chace 20/12/04

The Chace 07/09/04

The Chace 23/03/04

The Chace 09/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE The Chace Chase Road Upper Welland, Malvern Worcestershire WR14 4JY Lead Inspector Annie OMara Unannounced 22 July 2005 8:00 am 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. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Chace Address Chase Road, Upper Welland, Malvern, Worcestershire WR14 4JY 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) 01684 561813 Chace Rest Home Limited Mr Anthony William Reeley Care Home 34 Category(ies) of DE(E) Dementia over 65 both genders (34) registration, with number OP Old age both genders (34) of places PD(E) Physical disability over 65 both genders (26) The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: There are no additional conditions of registration. Date of last inspection 20 December 2004 Brief Description of the Service: The home provides a residential care service for a total of 34 people over the age of 65 years. The home is able to provide care for older people who are physically disabled and older people who suffer with dementia. The number of residential places for those who have a physical disability is 26. Respite care is available as is a day care service. The premises are situated in a village location in Upper Welland, near Malvern. They consist of an original building, formerly a country manor house, and a large extension. Accommodation is provided on two levels in both parts of the building. There are fourteen bedrooms on the ground floor, twelve of which have ensuites. There are eighteen bedrooms on the first floor, seventeen of which are ensuites. There are four bathrooms, three of which are adapted for people with disabilities and one which has a shower, also adapted for people with disabilities. Rails are provided in corridors.A garden area is available for use by service users.There is a rural bus service close to the home. The home has achieved Classic Homes Status and the Investors in People Award The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of three and a half hours on a weekday. During the inspection four residents and three members of staff were spoken to as well as the registered manager and administrator. Some care documents were looked at, and a brief tour of the building was made including visiting a resident in their bedroom. What the service does well: What has improved since the last inspection? The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 6 The provision of a new platform lift and new carpets has improved the facilities. 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 Chace E52 S18683 THE CHACE V237835 150705.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 The Chace E52 S18683 THE CHACE V237835 150705.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 The home provides information to help prospective residents and their families to make an informed choice about moving in to the home. The assessment process ensures that residents’ needs are understood and planned for prior to admission. EVIDENCE: Up to date information about the home and the services they offer was available to prospective residents and their representatives. Assessments were undertaken for each resident prior to them moving into the home to ensure their needs can be met. When available information was sought from any other agencies involved. Prospective residents were able to visit the home before moving in. Each resident was provided with a contract when they have decided they wish to stay permanently and this was confirmed by a resident. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 9, 10. The management of medication systems ensures the safety of residents. The care practices in the home promote residents’ privacy, dignity and independence. EVIDENCE: The administration of medication was well organised and efficiently managed. Staff administering medication received training and the member of staff who was spoken to about medication was very confident and knowledgeable about ordering, storage and recording of medications. Residents who were spoken to confirmed that staff were very respectful and called them by their proper names. Staff were able to give examples of how their practices promoted the residents privacy and dignity. Observations made during the inspection also indicated that residents were treated with respect and encouraged to remain independent. Residents said that staff were, “Extra good” “Very good”, “Approachable”. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 10 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, 15. The activities provided in the home promote the health and welfare of the residents and are tailored to meet individual and collective needs. The food provided by the home was varied and catered for residents with specialist needs. EVIDENCE: Routines in the home were flexible and one resident stated that “you could do what you liked”. There is an emphasis of importance put on the provision of meaningful activities that includes regular trips out into the community in the homes’ car. Whilst the organisation of activities was undertaken by one member of staff, all staff have the opportunity to be involved with them. Group activities were undertaken as well as individual time spent with residents. The provision of activities in this home is commendable. Residents were able to maintain their contact with family and friends. Residents who were asked about the food gave different views about it. They confirmed that they were given choice and were asked about the menus. Comments were “Better than it was”, “Alright”, “Very good” and “Quite nice but we could do with more variety”. Menus were displayed on the tables and choices and alternatives were offered. The dining room was attractively laid and the meal was unhurried. Residents needing some help with their food were given it most discreetly. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 11 The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 12 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 The ethos of the home is such that residents feel able to voice any concerns. EVIDENCE: A complaints procedure was freely available and residents spoken to said they felt able to bring their concerns up with staff. They were also confident that any concerns would be addressed. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 13 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, 23, 24, 26. The environment is maintained to a high standard, providing the residents with a very comfortable and homely place to live. Good hygiene practices promote the health and welfare of the residents. EVIDENCE: The home is well maintained and was very clean on the day of the inspection. The standard of décor is very high and new carpets have recently been fitted. A new platform lift has also been fitted for the benefit of residents. Some windows on the first floor did not have window restrictors on them and some radiators did not have covers on them. Requirements have been made in respect of these matters. There is a choice of communal rooms and a separate dining room. The garden is accessible and chairs and tables provided. Bedrooms visited have attractive views of the countryside. A resident confirmed she had been able to bring her own furniture in and was very content with her room. Again, the bedrooms are decorated to a high standard. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 14 Staff were observed to maintain good standards of hygiene in their practice. Staff spoken to said that they had received infection control training and residents confirmed that they always used gloves and aprons when providing personal care. The laundry room has been refurbished and is in the process of being decorated. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 15 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. Staffing levels were judged to be low in the afternoons/evenings and there was no formal system in place to indicate that this was regularly reviewed to ensure residents were not at risk. EVIDENCE: There were four members of care staff on duty during the morning and early afternoon shift and the activities organiser. On the evening shift there were two members of staff and a third person to help with the kitchen and domestic tasks. This is a very low ratio of staffing. There was no formal method of reviewing the staffing levels to ensure that residents’ needs were being met consistently in the evenings although it was stated that this was carried out regularly. Staff who were spoken to confirmed that they had received training in all key areas of health and safety. They also enjoyed working at the home. Residents who where asked about staffing levels had no concerns and said that help was there when they required it. There was no other evidence to suggest that residents’ needs were not being met. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 16 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. The management arrangements need to be resolved although there is no evidence to indicate that they have a negative impact on the care received by the residents. EVIDENCE: There is an outstanding requirement regarding the management arrangements for the home as the current manager, who is also the registered provider, does not undertake hands on care with residents. An administrator/manager has been employed and they are working towards a resolution of this matter. Both are undertaking NVQ level 4 training. There was no evidence to indicate that management systems were anything other than very efficient and effective. The requirement however is still in place. All policies and procedures in the home were being up dated and records relating to residents were being reviewed. The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 17 The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 18 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 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 3 x x x x x x The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 19 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 27 Regulation 23 Requirement A regular review of the afternoon/evening staffing levels must be undertaken and evidence available to show that residents needs are being met. The registered manager must gain the Registered Managers Award by the end of 2005. Timescale for action 30th September 2005 31st December 2005 2. 31 9 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 Good Practice Recommendations The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 20 Commission for Social Care Inspection The Coach House, John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 The Chace E52 S18683 THE CHACE V237835 150705.doc Version 1.40 Page 21 - 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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