Inspection on 24/11/05 for Chaldon Mead

This inspection was carried out on 24th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chaldon Mead 10/10/07

Chaldon Mead 06/03/07

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

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

CARE HOME ADULTS 18-65 Chaldon Mead Chaldon Mead 50 Rook Lane Chaldon Surrey CR3 5AB Lead Inspector Cathy Clarke Announced Inspection 24th November 2005 10:00 Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 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.V254240.R01.S.doc Version 5.0 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.V254240.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chaldon Mead Address Chaldon Mead 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 Oaklands NHS Trust Ms Mary Bergin Care Home 16 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (7) of places Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the category: Learning Disabilities (LD), 7 (seven) of whom may be within the category Learning Disabilities for older persons LD(E). The age/age range of the persons to be accommodated will be: 46-65 YEARS & OVER 16th June 2005 Date of last inspection 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 with the exception of one double room for two service users to share. 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. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 5 hours and was the second inspection to be undertaken by the Commission for Social Care Inspection year April 2005 to March 2006. Cathy Clarke, Lead Inspector for the service, carried out this inspection and Mary Bergin Registered Manager was present as the representative for the establishment. A full tour of the premises took place, documents inspected included care plans, staff records, training certificates and policies and procedures. All service users have completed comment cards with their key workers and some of their comments will be included in the report. Relatives, carers and Health and Social Care professional’s comments will also be included in the report. Some service users were unable to communicate verbally, their body language and non-verbal communication skills were observed during the inspection. This was a positive inspection. The inspector would like to thank the management and staff for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The statement of purpose has been reviewed and updated and reflects the current service provision. Individual plans are signed by the service user and a relative or representative. Risk assessments are in place for the use of bed-rails and a screen is in use in the shared bedroom. The food in the fridge has been labelled and dated. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 6 The bay window in bedroom number 12 has been replaced and the room has been painted. 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. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 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.V254240.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4 Comprehensive information regarding the home is available for prospective service users and planned assessments are undertaken prior to moving into the home. The home responds well to emergency admissions. EVIDENCE: The statement of purpose and service user guide have been reviewed and updated to include the new registered name of Surrey and Borders Partnership Trust. There has been one emergency admission to the home since the last inspection and the registered manager kept the Commission for Social Care Inspection informed throughout this process. The assessment process has been fully implemented for this service user in line with the care management referral and plan of care. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,10 Care plans and risk assessments are clear and set out the achievements made by service users. Confidential information is stored appropriately and handled appropriately. EVIDENCE: Each service user has an individual folder with a good range of care plans, risk assessments and person centred plans. Separate risk assessments are in place for manual handling and the use of bedrails. Two of the files sampled did not have current photographs of the service users. A General Practitioner who visits the home has stated that if advice is given to staff that they act on it and it is noted in the service users records. A key worker system is in place for all service users. Staff demonstrated that they can meet the communication requirements that service users have during the inspection. All service users have stated that they like living at the home. Confidential information is kept in locked filing cabinets. Computers are password protected and there is a confidentiality policy and procedure in place. Please see requirements section of this report. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15,16 Service users take part in age and peer appropriate activities and maintain links with family and friends. EVIDENCE: Some of the service users had gone out to a local café to celebrate one of the service users birthday. Service users attend local amenities and day centres. During the inspection the inspector went into the adjacent day centre and service users were enjoying making xmas cards. Service user files sampled held a weekly timetable of activities including, art therapy, woodwork, walking, swimming, shopping, church, and visits to the local pub. One of the service users has a large train set displayed in his room. Service users have enjoyed holidays abroad. Family and representatives are encouraged to be fully involved in the care of service users and to attend review meetings. There are no restrictions on visiting times. Visitors to the home have stated that they can visit in private and that they are satisfied with the overall care provided. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 11 One of the service users likes to lock her bedroom and holds the key. Key workers assist service users with making appropriate decisions and choices. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 The health needs of the service uses are well met with regular review meetings. EVIDENCE: Health screening appointments were seen on file and psychological assessments in place. One of the service users was unwell during the inspection and the local GP had visited the previous evening and prescribed medication. The GP was again requested to visit this service user to assess his health care needs. Service users have regular appointments with dentists, district nurses, opticians and dieticians. Physiotherapy and occupational therapy sessions have been provided for some service users. A district nurse for the service has stated that the home communicates clearly and that they work in partnership. The occupational therapist has visited the home and grab rails have been fitted. One service user who used to use a Zimmer frame is now able to use the grab rails to move freely around the home. One of the requirements from the previous inspection related to the arrangements made for the aging illness and death of a service user. Discussion was held with the registered manager and a revised timescale was Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 13 agreed in order to ensure that the resulting documentation was exactly what was required by the service in the longer term. Please see requirements section of this report. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Staff have received training in the protection of vulnerable adults using the Surrey Multi Agency Approach procedures therefore ensuring that staff are aware of any potential signs of abuse. A complaints policy and procedure is in place. EVIDENCE: There has been one complaint since the last inspection, which has been responded to appropriately, and an action plan put into place to ensure that this incident does not reoccur. All service users have stated that staff treat them well and listen to them. Comment cards received from visitors, district nurse, and GP have stated that they have never had to make a complaint. Service users have indicated on comment cards that they know who to complaint to. There have been no vulnerable adult investigations since the last inspection. Staff files sampled confirmed that staff have been trained on how to safeguard adults. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,30 Services users live in a homely, comfortable environment, which is clean and hygienic. A redecoration programme is required for some rooms. EVIDENCE: On the day of inspection the maintenance team were in the building fitting a new shower room. The hot water system within the home has recently been maintained and an extra tank is to be installed. The premises are in keeping with the local community and the garden is well maintained. The bay window in bedroom number 12 has been replaced and the room has been painted. The bay window in the dining room has been replaced and curtains were being fitted during the inspection. The following maintenance issues were raised during the inspection with the registered manager and deputy manager. The ceiling in room 1 must be repainted to cover stains. Room 8 has been decorated some time ago and must be redecorated to the taste of the service user. Room 13 must be redecorated prior to any admissions to this room. The carpet in room 15 must be cleaned. New toilet seats are to be replaced in two Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 16 of the toilets. The carpet on the stairs up to the dining room is worn and needs replacement. Moss must be eradicated from the fire escape to prevent trips and falls in the event of an emergency. Both service users who share a bedroom have stated that they would prefer to have a single room. This was discussed with the registered manager who has agreed to speak with both service users. There are not suitable rooms available at the present time to relocate them to should they wish to move into their own rooms. A screen is in use in the shared bedroom. The home is clean and tidy and there were no mal odours. The kitchen was very clean the fridge and freezer temperatures were within limits. The chef deep cleans the kitchen every month. Service users were to have ham, potatoes, carrots, swede and parsley sauce for lunch with fruit salad and cream for sweet. The home has a green house in the garden and the chef and service users have tended to the homegrown vegetables throughout the season. This has provided the home with fresh vegetables and much enjoyment for the service users. Please see requirements section of the report. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 There are adequate numbers of suitably trained staff to meet service users needs. Agency staff have been inducted and trained by the provider. Criminal record bureau enhanced disclosures were not in place for all staff members. EVIDENCE: On the day of inspection there was adequate staff to meet service users needs. All service users were up and dressed and were doing the various activities on offer for them. Staff interviewed during the inspection confirmed that they had worked for the organisation for some time and they receive regular supervision and appraisals are conducted annually. Supervision notes confirm that policies and procedures are discussed with staff. One member of staff has transferred to the home from another Surrey and Borders Partnership NHS Trust home and her recruitment records did not contain evidence of a Criminal Record Bureau Enhanced disclosure. One other staff members CRB is outstanding. All staff have received mandatory training and 54 of the staff group hold a relevant NVQ qualification. Annual manual handling refresher training is provided. Staff have undertaken first aid and food hygiene training. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 18 Agency staff have received fire refresher training and receive regular supervision. The registered manager has attended the Surrey Multi Agency Approach training for Safeguarding Adults and all staff have received protection of vulnerable adult training. Please see requirements section of this report. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 Staff and management offer a consistent, well-managed and planned service, which is underpinned by clear and concise health and safety policies and procedures. EVIDENCE: The registered manager and staff of the home demonstrated a good level of knowledge and the skills required to provide services to service users with a learning or physical disability. Risk assessments for the home are in place and the shift leader undertakes safety audits quarterly. Equipment in the home has been safety checked and the lift was serviced at the beginning of November. Policies and procedures are in place for Health and Safety within the home. Health and safety training is provided for all staff. The home has motor insurance in place for the homes vehicle and a current MOT certificate. The tail lift has been recently safety checked. Chaldon Mead DS0000013590.V254240.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chaldon Mead Score X 3 X 2 Standard No 37 38 39 40 41 42 43 Score 3 X X X X 3 X DS0000013590.V254240.R01.S.doc Version 5.0 Page 21 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 2 Standard YA6 YA21 Regulation 17 (1) (a) schedule 3 12 (3) Requirement Current photographs of service users must be put onto their service user files. Plans must be in place to deal with ageing, terminal ilness and death agreed with the service user and relative or representative. This standard was not met from the previous inspection and a revised timescale has been agreed. The ceiling in room 1 must be repainted to cover stains. Room 8 must be redecorated to the taste of the service user. Room 13 must be redecorated prior to any admissions to this room. The carpet in room 15 is to be cleaned. New toilet seats are to be replaced in two of the toilets. The carpet on the stairs up to the dining room must be replaced. Moss must be eradicated from the fire escape to prevent trips and falls in the event of an DS0000013590.V254240.R01.S.doc Timescale for action 31/01/06 31/03/06 3 4 5 6 7 8 YA24 YA24 YA24 YA24 YA24 YA24 23 (2) (d) 23 (2) (d) 23 (2) (d) 23 (2) (d) 13 (3) 23 (2) (b) 23 (2) (b) 31/03/06 31/03/06 31/03/06 31/01/06 31/01/06 31/03/06 9 YA24 13 (4) (a) 31/12/05 Chaldon Mead Version 5.0 Page 22 emergency. 10 YA34 19 (1)(b) (ii) Criminal record bureau enhanced disclosures must be in place for all staff. 31/01/06 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 YA25 Good Practice Recommendations It is recommended that the service discuss with the service users in the shared room their preferences for a single bedroom. 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