Inspection on 02/10/07 for Chalcraft Hall Care Home

This inspection was carried out on 2nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chalcraft Hall Care Home 07/06/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Chalcraft Hall Care Home 76 Chalcraft Lane North Bersted Bognor Regis West Sussex PO21 5TS Lead Inspector Clare Hall Unannounced Inspection 2nd October 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000065445.V347215.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000065445.V347215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalcraft Hall Care Home Address 76 Chalcraft Lane North Bersted Bognor Regis West Sussex PO21 5TS 01243 821368 01305 889038 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anra Care Limited Mrs Angela Barton Care Home 20 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (9) of places DS0000065445.V347215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2006 Brief Description of the Service: Chalcraft Hall is a residential home providing accommodation and personal care for up to twenty elderly persons. The current owners purchased the home in November 2005. The registered provider is Anra Care Limited for and the registered manager is Mrs Angela Barton. The home is situated in a residential area on the outskirts of Bognor Regis close to a local shopping parade and within easy distance of the town centre with it’s train station, shops and other amenities. The detached building is set in good-sized gardens consisting of paved and lawned areas. There is ample parking space to the front/side of the building. The accommodation is arranged on ground and first floors and there is a passenger lift. All rooms are for single occupancy, seventeen having full ensuite facilities and three with a WC and washbasin. There are two lounges and a separate dining room on the ground floor. DS0000065445.V347215.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried out by Mrs C Hall, regulatory inspector. The information used to write this report was gained from the homes Annual Quality Assurance Assessment; a visit to the service and a review of comment cards received from staff, relatives, and health and social care professionals. The Commission uses people with experience of the client group to assist on some inspections and an ‘expert by experience ‘ was used as part of this inspection. This person spent time sitting with residents discussing matters relating to individual wishes and needs. Other information was gathered from the services history of events, previous inspection reports, direct conversations with staff, analysis of information supplied to and recorded by the link inspector. The findings of the inspection were discussed as they arose with the manager and discussed with the providers at the end of the day. The provider is exploring the feasibility of increasing the number of beds registered for people with dementia. What the service does well: Residents said, “There are four marvellous carers,” and, “ All the girls are very supportive and friendly.” A comment from a survey reported, “I think the care home is excellent, the residents are happy, fed well and the home is so clean.” One survey from a professional stated, ”When observing learners I can see that the training they have attended has been incorporated through to their working practice.” DS0000065445.V347215.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000065445.V347215.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065445.V347215.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4, People who use the service experience good quality outcomes in this area. Some residents and their families have sufficient information they need to make an informed choice of where they live. However, the home does not include the fees people are required to pay in the resident’s contract of residence. The surveys completed by some relatives showed that they had their relative did have a contract. Service users have a full assessment before moving into the home. Residents and their relatives are provided with information about the home prior to being admitted and prospective residents are able to visit the home for tea prior to making the decision. Relatives and residents who responded to the inspector felt this to be adequate. EVIDENCE: The Service Users Guide and Statement of Purpose provide the information for residents but does not state the fees which is now a legal requirement DS0000065445.V347215.R01.S.doc Version 5.2 Page 9 The resident’s files did not have contracts in them to show what the terms of accommodation were or what the fees were, although residents and relatives who were invited to comment on the service all said they had a contract. The provider is advised to ensure that a copy is left in the home for inspection. When the residents were talking with the expert by experience it could not be established whether they had received any information about their terms of stay or whether they had been consulted about their care plan. Notes made show that several residents told the person they couldn’t remember as they had memory loss problems. However both residents and relatives said they were aware of who to go to if they had a problem about a relatives care. Of the three resident files seen all had records indicating that they had undergone a full assessment of their needs. A care manager in the home at the time of the inspection said she used the home for several of her clients and was pleased with the level of care provided, including pre assessment. DS0000065445.V347215.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Records show considerable improvement has been made for the assessment of residents and the recording of their needs and preferences. EVIDENCE: A community health worker was heard informing the manager that a resident with an infection did not have the necessary hand washing equipment, aprons or yellow bags provided in her room and to prevent this spreading, such measures needed to be introduced. Four care records were assessed and indicated that they had recently been reviewed and updated. The details recorded covered all aspects of health, well-being, preferences choices and desires of the residents. DS0000065445.V347215.R01.S.doc Version 5.2 Page 11 Assessments in relation to falls, nutrition, manual handling were in place and records held pen pictures of what the residents history was in relation to likes dislikes, occupation and future expectations. Care staff were observed updating records and using them as a reference as they worked. Staff spoken with reported a different opinion as to how they viewed the care provided and senior staff felt there had been an improvement in the level of care given. Eleven of the care staff have received training in the administration of medicines in the last year. Care staff were observed giving medications and seen referring to the administration records as they did this. Information as to what the medication is used for is available as an aide memoir for staff should a resident wish to know why they take a particular medicine. The information also includes the date the medicine was last reviewed by the GP, a list of all medicines taken by each resident and possible side effects to look for. Staff gave mail to residents for them to open and stood waiting discreetly in case they required help opening it. However, another member of staff was observed turning off a resident’s television without asking her first. The registered persons are should ensure that the personal preference of a resident is met to ensure that dignity and respect is not compromised. DS0000065445.V347215.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff record the interests, choices and preferences of residents. EVIDENCE: Records indicate that staff have consulted with residents to establish the residents preference as to the time of getting up and their preferred early morning drink. Residents are asked how they prefer to be addressed. One resident told the expert by experience that she gets up when she wants and said, “the staff know that I like to get up early.” Through out the morning the inspector observed residents coming into the dining room to have breakfast at the time they preferred. Staff were using the only television in the residents lounge to watch their training videos. Care must be taken to ensure that such activity is acceptable to the residents . DS0000065445.V347215.R01.S.doc Version 5.2 Page 13 Residents were generally positive about personal choice and some said they would like more activities. The manager has identified this with the providers as an area that needs development. One resident when asked whether they had any say when choosing activities, said, “they never ask us.” Records showed that staff had consulted residents about their food and drink preferences. All files seen had up to date details of residents weight and their Body Mass Index and a nutritional risk assessment. Staff were observed weighing residents as part of their risk assessments where this is required. Relatives ,residents and staff who responded to the survey before the inspection were all complimentary about menus and the food available, including choice. DS0000065445.V347215.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience poor outcomes in this area This judgement has been made using available evidence including a visit to this service. There is not an audit trail of complaints and safe guarding concerns in the home to adequately demonstrate that these concerns are addressed in line with the homes policy. EVIDENCE: The last recorded complaint was in 2005 and the manager said she has not received any complaints since then. A safeguarding alert was referred to the West Sussex County Council Safe guarding Team. However, there were no records in the home to indicate this event had occurred or what the outcome was. The AQAA indicates that the owner of the home has a quality assurance system in place and this gives residents the opportunity to comment on the service provided. Residents and relatives who responded to the inspector’s request about care in the home, all said they knew how to complain and who to go to, but had not needed to use the Complaints Procedure. DS0000065445.V347215.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26, People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service does not currently provide a safe, well maintained environment for people to live in. Suitable communal facilities are provided, however, not all call bells and bathing equipment are maintained in working order or are accessible to residents which could result in urgent calls for assistance to be missed. Signage needs to be improved to ensure residents can find bathrooms and their bedrooms. Parts of the building require significant maintenance and updating. The current environment needs improvement if it is to provide accommodation that meets the providers aims and objectives and as detailed in the Statement of Purpose. DS0000065445.V347215.R01.S.doc Version 5.2 Page 16 Residents are included in the choice of furnishings and decoration when their room is refurbished. Residents are encouraged to take small items of their own furniture and some possessions when they move into the home. EVIDENCE: Residents benefit from two lounges and a dining room and one lounge has a television in it. The majority of bedrooms have full en-suite facilities and three have a wash basin and WC. The gardens are well maintained and there is good parking for visitors. The environment will need a programme of maintenance to ensure that signage, equipment and facilities are available to meet the needs of more people with dementia. The provider has said in his AQAA that he intends to upgrade the premises and it is intended that this will address the current shortfall in the environment referred to in this report Currently bedroom doors are not fitted with a suitable lock to ensure that personal possessions can be kept secure and personal privacy respected. The use of keys when they are fitted should be risk assessed to prevent inappropriate use and risk to service users. A resident told the ‘expert by experience’ that residents walk into her room uninvited. This must be monitored by staff to ensure that each residents privacy and dignity is not compromised. Toilets and bathrooms do not have suitable signage to help residents with a memory impairment to identify them and nor is their adequate signage on peoples rooms. Repairs to the toilet on the ground floor ,have according to some staff been outstanding for several months but residents are not always able to read the small sign on the door saying it is broken. The Fire Office must be consulted as to whether the maintenance of emergency lighting is included in the services risk assessment and that the assessment meets the requirements of their legislation and protects the health and welfare of service users. One window upstairs without a restrictor was repaired during the inspection. An electrical socket adjacent to a bath was discussed and the registered provider was advised to contact an electrician to confirm that this meets DS0000065445.V347215.R01.S.doc Version 5.2 Page 17 current legislation and does not put residents at risk. The owner was made aware that exposed pipe work in residents rooms must be covered it carries hot water. Where maintenance programmes are delayed or not in place due to the anticipated improvements to the environment, the owner should consult with an Environment Health officer to ensure that all areas of the home are safe and meet the current legislation for a safe environment for residents and staff. The laundry floor is part tiled and part covered in linoleum and is not of a material which can be cleaned to a standard that reduces or remove the risk of infection. Some staff when asked what the service could do better referred to the need to improve laundry facilities. The provider has plans for a new laundry but as an interim measure to ensure residents are not at risk of infection because of poor laundry hygiene should discuss the matter with an Environmental Health officer. The manager and provider said they did not have the recent guidance from the department of health regarding the control of infection in Care Homes, although this conflicts with a reference in the assessment of the home which said Environmental Health officers were satisfied with the infection control procedures in the home. DS0000065445.V347215.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, People who use the service experience poor quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Staffing levels are not always sufficient to meet the assessed needs of residents. Some staff are employed without the necessary checks being undertaken before they start employment, which may put residents at risk of being abused. EVIDENCE: One member of staff said that on occasions when staff went off sick only two staff were on duty in the afternoon, the manager would not employ agency staff to cover. They said two staff was not sufficient to provide safe care. One resident comment card said, “If they are not too busy they are very attentive.” The manager does not promote the use of agency staff because in her opinion they require time spent on induction and do not offer much benefit but agreed staffing levels in the past month had been lower than usual. This is at variance with the AQAA provided by the owner which shows three staff on duty at all times. DS0000065445.V347215.R01.S.doc Version 5.2 Page 19 Three staff files were assessed and whilst all had a POVA and CRB checks, they had not been returned at the time of employment. This may place residents at risk and should only happen in exceptional circumstances The two references held obtained as part of the recruitment process were from friend and colleagues and not the last employer. The application form for employment, requests details of the last employer and to ensure residents are safeguarded this reference must be obtained. The provider discussed the difficulties the home was experiencing with the recruitment and retention of care workers. Of the three files assessed one had no records to show they had received any training during the four months of employment. However, three newly appointed staff were observed receiving induction and watching training videos and two records indicated training had been received in communication, safeguarding, food hygiene death and dying and medication. Senior staff were overheard discussing induction records and observed signing induction competences. DS0000065445.V347215.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Service users live in a home that is run and managed by a person who is fit to manage the service. The variance in providing staff in sufficient numbers affects the lives of residents in that reduced staffing levels will have an impact on the ability of the service to be run in the best interests of residents. Therapeutic activities to maintain and develop residents quality of life are not possible to achieve on reduced staffing levels. DS0000065445.V347215.R01.S.doc Version 5.2 Page 21 EVIDENCE: Angela Barton is the registered manager and holds an NVQ4 in Care and the Registered Managers Award. The home has a quality assurance programme and surveys are sent to residents and staff. Staff reported to the inspector during discussions and in surveys that the manager was approachable and supportive. The manager was seen interacting with staff working along side them and guiding senior staff. The manager stated that the home does not handle any service users monies. Records indicated the list of charges made for each resident for items such as hairdressing and chiropody. The manager explained the receipts for these services are sent to the head office and families are then invoiced for their relatives purchases. The majority of staff have received mandatory training and this is an area the manager, senior staff and providers are giving attention to. The health and welfare of residents may be compromised by the poor environmental standards identified in other sections of this report. The manager must ensure that she is working actively with the owner to maintain health and safety whilst the programme of refurbishment is being planned. In undertaking this work it is the responsibility of the registered persons to consult with other agencies to ensure compliance and safety of residents and staff. DS0000065445.V347215.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 1 3 2 X 1 1 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X X 1 DS0000065445.V347215.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP2 Regulation 5 Requirement All residents must be provided with contracts, which describe the terms of their residency including the fees payable Complaints must be investigated and records maintained in the home in accordance with the services policies and procedures The environment must meet the needs of the residents. It must be in good state of repair, safe with adequate lighting and have suitable facilities. Staff must only be employed after all checks have been completed. Timescale for action 01/12/07 2 OP16 22 01/12/07 3 OP19 13 and 23 01/02/08 4 OP29 19 Schedule 2 and 12 01/12/07 5 OP27 18 (1) (a) Staff must be employed in sufficient number to ensure a safe service is provided to residents at all times 01/12/07 DS0000065445.V347215.R01.S.doc Version 5.2 Page 24 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 OP19 OP25 OP26 OP38 Good Practice Recommendations The registered persons are advised to consult with Fire and Environmental Health Officers to ensure that the environment is maintained to a standard whereby it is free from hazards and risks to service users and staff. 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