Inspection on 10/10/07 for Chaldon Mead

This inspection was carried out on 10th October 2007.

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

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

Other inspections for this house

Chaldon Mead 06/03/07

Chaldon Mead 24/11/05

Chaldon Mead 16/06/05

Chaldon Mead 07/12/04

Chaldon Mead 11/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Chaldon Mead 50 Rook Lane Chaldon Surrey CR3 5AB Lead Inspector Kenneth Dunn Unannounced Inspection 10th October 2007 09:15 Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 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 Chaldon Mead DS0000013590.V345864.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 Adults 18-65. 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. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaldon Mead Address 50 Rook Lane Chaldon Surrey CR3 5AB 01883 383820 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) Surrey and Borders Partnership NHS Trust Ms Mary Bergin Care Home 15 Category(ies) of Learning disability (15), Learning disability over registration, with number 65 years of age (7) of places Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2007 Brief Description of the Service: Chaldon Mead is a detached property located in the village of Chaldon. Accommodation and care is provided for up to sixteen service users with learning disabilities. Service users benefit from a day care centre, which is situated next to the home. All bedrooms are single. There are adequate communal areas including a quiet room. There is a large enclosed garden to the rear of the property backing onto a golf course. The home has its own transport for service users and there is ample car parking space to the front of the property. The weekly fee at this home is £917.38. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over five hours. Mr. Kenneth Dunn, Regulation Inspector, undertook the site visit on behalf of the CSCI. A full tour of the premises took place. Discussions with people who use the service and staff were held informally to canvass their experiences of the home. An annual quality assurance assessment (AQAA) was supplied to the home by CSCI, and this was completed and returned. Information from the AQAA will be referred to in this report. The AQAA states that the home has policies and procedures to promote equality and diversity and all staff have received training, to increase their knowledge and awareness of these issues. The final report takes into account detailed information provided by the registered provider, Annual Quality Assurance Assessment (AQAA), returned surveys (next of kin, medical professionals, care manager and any other interested representatives of the residents) in addition any information that the CSCI has received about the service since the last inspection will also be used to complete this report. The Commission for Social Care Inspection would like to thank the veterans, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? The previous inspection was very positive. The home continues to develop in order to meet the needs of the people who live there. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are fully assessed and explored prior to admission to the home. EVIDENCE: There have been no admissions to the home since the previous visit. Evidence sampled concluded that pre admission assessments are completed prior to any individual moving into the home. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with an individual care plan, which records their individual needs and goals. Service users are supported to make decisions about their lives with assistance. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The inspector sampled care plans for three service users. Each service user has a completed care plan which were person centred in approach and based on full needs assessment including personal care, health and emotional needs, communication, safety and social skills. Individual plans were of a good standard detailed and structured with clear priorities, objectives and goals recorded. Clear support plans were in place for routines and strengths it clearly defines individual preferences for example favourite community and leisure activities, favourite diet and favourite tasks. It was evident that plans were regularly reviewed with annual, six monthly and monthly reviews recorded. There is a Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 10 key worker system in place and two members of staff spoken to were aware of the care plans and their involvement in the review processes. Service users are supported to be an active participant in their care plans development and there is clear evidence that they are invited to attend their own reviews. The inspector sampled a wide range of risk assessments they were comprehensive and detailed and included personal care, health, development skills including the use of the kitchen. Some individuals have emotional difficulties, which could lead to possible aggression to other with clear plans and management guidelines in place. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of appropriate activities and engage in a range of leisure activities. Service uses are supported to take part in the local community. The rights and responsibilities of service users are respected. The home is able to demonstrate that service users are provided with a wellbalanced and nutritious diet. EVIDENCE: The home provides a range of recreational and leisure activities for service users to attend. It was clear that activities were tailored to suit individual needs and preferences. An activity plan was available for each individual and three plans were sampled which included for example attending Day Centres, arts and crafts, music sessions, shopping trips, pub visits And one individual is supported to attend a local Mosque. The service users are supported to assist in household activities. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 12 The service has arranged annual holidays for the service users. One service user told the inspector who much he had enjoyed his holiday in Spain and another was very proud of the souvenirs he had brought back from Paris. The inspector was informed that a third group of service users and staff had a very active holiday here in the UK on Hailing Island. There is good evidence of the staff supporting the service users to maintain links with their family and friends. One of the service users files sampled during the visit clearly demonstrated the work undertaken by staff to ensure that the service user kept in touch with her family. The inspector sampled copies of the homes menus, which were varied and well balanced with service users being given the opportunity to make choices about their meals, and this is discussed as an agenda item at service users meetings. The inspector was informed that one of the service users has a restricted diet based upon religious convictions. A member of staff stated that although the service can not meet strict Halal requirements they do endeavour to met the individuals dietary needs by ensuring that a choice is available or supporting the service user to get a take away from a Halal restaurant. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that service users receive personal support in the way they prefer. Service users physical and health needs are met. Service users are protected by the homes medication administration procedures. EVIDENCE: The preferences, likes and dislikes of service users were clearly recorded in their individual care plans the information contained details of meals and activities support plan for example morning routine. One plan that was sampled contained very detailed information to ensure that the service users is fully supported in the way the individual wants down to niceties about the perfumes and skin product this person likes to wear. The health care needs and objectives of service users are documented in their care plans and the home has completed health action plans. Three health care plans were sampled which contained detailed information of the health care needs of individuals including records of health appointments and screening checks. One individual had a support plan in place for epilepsy and is supported by a specialist epilepsy nurse. Service users are supported to access Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 14 a range of health care professionals for example a local general practitioner, community psychiatric nurse, district nurse and chiropodist. The homes Medication administration practices were examined. Procedures were in place including a copy of the Royal Society Pharmaceutical Guidelines. Protocols were in place for service users receiving “As required” medication. Three medication administration cards were examined. Photographs of service users were available with their records and a list was available for all staff that are trained and authorized to administer medication. All medication administered was signed for. The home appropriately maintains records for all medication received and disposed of. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that the views of service users are listened to and acted upon. Service users are protected from abuse. EVIDENCE: A complaints procedure is available and is accessible to residents and is printed in service user-friendly format. The complaints policy is contained in the service users information pack. The inspector was informed that all the service users receive a copy, which they can keep in their bedrooms. The policy has been developed in pictorial and widget symbol format in order to allow people with learning disabilities to engage in the complaints process. The support worker informed the inspector that issues raised by service users are dealt with instantly before they can become complaints. Written comments received from family members of service users indicate that they are aware of whom they can approach if they were to make a complaint. There is a clearly written safeguarding adults procedure and a copy of the local authority safeguarding adults from abuse policy was available. The contact details for the local authority Social Care Team was also displayed. The manager has attended the local authority protection of vulnerable adult training and staff records sampled indicates that staff have been attending training. One member of staff spoken with confirmed her attendance at training and was clear in her responses to indicate that she was aware of the policies and procedures. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed during this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises are in need of repair and refurbishment, to ensure service users have a safe, comfortable and homely environment to live in. EVIDENCE: The main lounge was found to be clean and well presented the service users bedrooms were clean personalised and clearly demonstrated the personalities of the individuals who occupied them. However in one of the bedroom the staff were using the room to store the services hoist, the inspector was informed that the service user occupying the room did use the hoist but it was for the use of all the service users. In addition the staff had put up handwritten notices in respect of the hoist and its charging on the wall above the service users bed, as if the bedroom was a storage area. The building is generally in need of redecoration and refurbishment in areas the wallpaper is coming away from the walls and ceilings, carpets throughout Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 17 the service are heavily stained and frayed the bathrooms are institutional and the dining room is a conglomeration of old and borrowed furniture that is not suitable for the service users. It was also a concern that on the day of the visit the house was very cold and the inspector made comments about the cold throughout the inspection. The inspector was informed that a capital budget was under negotiation for the works that are to be undertaken at Chaldon Mead but in light of the potential health and safety of the service users the refurbishment of certain areas must be seen as urgent. The majority of the home was clean and hygienic with adequate hand washing facilities being available, however in certain areas there was strong urine smell after cleaning. This was discussed with the member of staff assisting in the visit and it was suggested that a more suitable form of floor covering might elevate this ongoing situation. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 18 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a stable, competent and qualified staff group. Service users are protected by the trusts recruitment policy. Staff training is appropriate to the needs of the individual service users. EVIDENCE: The inspector sampled copies of duty rotas, which indicated that adequate staffing levels are maintained in the service. The inspector was informed that a number of staff have completed National Vocational Qualifications (level 2) or above with some staff completing the programme. Three members of staff records were sampled. Each member of staff has their own training record in place and it was evident that staff have received mandatory training in safeguarding adults, fire, food handling, food hygiene manual handling, health and safety, first aid and managing medication. The inspector was informed that staff receive training in epilepsy and other examples of training completed was continence promotion and rights and responsibilities. New staff receive induction training based on Skills For Care standards. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 19 The home has a good recruitment policy and procedure, based on their equal opportunities policy that has the needs of the service users at its core, however it was not possible to evidence if this is being adhered to, as there was no access to staff files in the absence of both registered manager and deputy manager. It was noted that all members of staff were recorded as having had an application to the Criminal Record Bureau (CRB). Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 20 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed during this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that service users benefit from a home, which is well run, and in the best interests of service users. The health safety and welfare of service uses should be reviewed. EVIDENCE: The registered manager is a qualified nurse with many years experience in caring for and managing care needs of people with a learning disability. The home holds regular staff and service user meetings and the Responsible Individual carries out monthly regulation 26 monitoring visits to the home this was confirmed by a random sample of the records. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 21 Substances hazardous to health (COSHH) were stored securely and appropriately. Health and safety checks are completed and recorded regularly which were sampled including fire prevention records, fridge and water temperatures. The manager provided information to indicate that records and certificates and identified systems are in place for routine service and maintenance arrangements for the environment. Chaldon Mead DS0000013590.V345864.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 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Chaldon Mead DS0000013590.V345864.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. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations The registered provider should ensure that the internal communal areas of the home are fit for purpose. Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Chaldon Mead DS0000013590.V345864.R01.S.doc Version 5.2 Page 25 - 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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