Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 18/07/07 for Chalfont Lodge Nursing Home

Also see our care home review for Chalfont Lodge Nursing Home for more information

This inspection was carried out on 18th July 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home`s assessment process ensures that positive outcomes for people using the service is achieved and the facilities provided meet individuals` diverse needs. The home`s care documentation reflects a person centred approach of caring and there are systems in place to ensure that the health and personal care of people using the service is based on their individual needs.The home provides a variety of activities to ensure that people using the service have a range of opportunities to participate in stimulating and meaningful activities. The home ensures that people using the service maintain contact with family, friends and the local community. The home ensures that people using the service are provided with a high standard of food that is well presented in pleasing surroundings. The home ensures that people using the service have access to an effective complaints procedure and there are policies and procedures in place to protect them from any potential abuse. The home ensures that people using the service live in a well-maintained environment that is clean, pleasant and hygienic. The home ensures that people using the service are cared for by staff who are trained skilled and appropriately recruited. The home has systems in place to ensure that it is run in the best interests of people using the service.

What has improved since the last inspection?

The home has reviewed its care documentation to ensure that it reflects a person centred approach of caring. All staff have undertaken training in the use of the new care plan format to ensure effective use of the documentation and the development of a more holistic care perspective by staff. The home`s training programme has been improved to ensure that all staff undertake updated mandatory training and other specialist training such as dementia training. The home`s recruitment procedure has been improved to ensure that it complies with current guidelines.

What the care home could do better:

Doors must not be wedged open with obstacles and doorstoppers to ensure that people using the service are protected from avoidable risks to their health and safety in their environment. The service should invest in the appropriate scales to allow staff to maintain and record the weights of people using the service who are not able to weight bear. When administering controlled medication to people using the service staff should record their full signature to ensure that entries and signatures are clear and legible. The practice of leaving prescriptions on clipboards should be reviewed to minimise any potential risk of loss to people using the service. A recent photograph should be held on all staff members` files to confirm proof of identification. The service should ensure that carers from within the European Union apply to register with the home office as soon as they begin working to ensure that staff with the appropriate working status look after people using the service.

CARE HOMES FOR OLDER PEOPLE Chalfont Lodge Nursing Home Denham Lane Chalfont St Peter Bucks SL9 0QQ Lead Inspector Joan Browne Unannounced Inspection 16th & 18th July 2007 10:00 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 DS0000019191.V343082.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. DS0000019191.V343082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalfont Lodge Nursing Home Address Denham Lane Chalfont St Peter Bucks SL9 0QQ 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) 01753 888002 01753 893668 Chalfont@barchester.com www.barchester.com Barchester Healthcare Plc Vacant Care Home 119 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (43), Physical disability (28) of places DS0000019191.V343082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. General Nursing Care Specialist Nursing Care (Physcially disabled 30 years plus) Date of last inspection 24th June 2006 Brief Description of the Service: Chalfont Lodge is a large purpose built nursing home set in pleasant landscaped grounds adjacent to Gerrards Cross golf course and approximately two miles from the centre of Chalfont St Peter. It is operated by Barchester Healthcare PLC, which owns over 160 nursing and residential homes across the country. The home can accommodate 119 service users across three areas of care: younger physically disabled, elderly physically frail, and elderly mentally frail. The home provides for a wide range of needs and abilities. All areas of the home are accessible by wheelchair. All 93 single rooms and 13 double rooms have en-suite facilities. Room sizes exceed the minimum standards. A first level nurse is in charge of each area: (i) Turnberry Unit (for younger people with a physical disability), (ii) Sunningdale Unit (for physically frail older people), and, (iii) Gleneagles, Wentworth and St Andrews Units (for mentally frail older people). There are many communal areas in the home including a library and large conservatory, which overlooks a small lake. The homes dining room provides a pleasant ambience and good quality food is served by waiting staff. The home aims to provide good standards of care and good quality hotel facilities. The fees range from £1,111.00 – £1,250.00 per week. DS0000019191.V343082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out over two days. The inspector spent approximately fourteen hours in the service and looked at how well the service was doing. The inspection took into account detailed information provided by the service’s support manager and operations manager. Comment cards were sent to some residents their relatives and health and social care professionals. At the time of writing this report response to comment cards had been received from four relatives, two residents and four health and social care professionals. Their views and the views of residents who were spoken to during the inspection are reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined, which was followed by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with staff rosters, staff recruitment files, training records and health and safety records. A tour of the premises was carried out and some time was spent meeting with residents and staff. Three relatives who were visiting at the time of the inspection were spoken to. From the evidence seen it was considered that the home was providing a good service to meet the diverse needs of individuals of various religion, race and culture. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: The home’s assessment process ensures that positive outcomes for people using the service is achieved and the facilities provided meet individuals’ diverse needs. The home’s care documentation reflects a person centred approach of caring and there are systems in place to ensure that the health and personal care of people using the service is based on their individual needs. DS0000019191.V343082.R01.S.doc Version 5.2 Page 6 The home provides a variety of activities to ensure that people using the service have a range of opportunities to participate in stimulating and meaningful activities. The home ensures that people using the service maintain contact with family, friends and the local community. The home ensures that people using the service are provided with a high standard of food that is well presented in pleasing surroundings. The home ensures that people using the service have access to an effective complaints procedure and there are policies and procedures in place to protect them from any potential abuse. The home ensures that people using the service live in a well-maintained environment that is clean, pleasant and hygienic. The home ensures that people using the service are cared for by staff who are trained skilled and appropriately recruited. The home has systems in place to ensure that it is run in the best interests of people using the service. What has improved since the last inspection? What they could do better: DS0000019191.V343082.R01.S.doc Version 5.2 Page 7 Doors must not be wedged open with obstacles and doorstoppers to ensure that people using the service are protected from avoidable risks to their health and safety in their environment. The service should invest in the appropriate scales to allow staff to maintain and record the weights of people using the service who are not able to weight bear. When administering controlled medication to people using the service staff should record their full signature to ensure that entries and signatures are clear and legible. The practice of leaving prescriptions on clipboards should be reviewed to minimise any potential risk of loss to people using the service. A recent photograph should be held on all staff members’ files to confirm proof of identification. The service should ensure that carers from within the European Union apply to register with the home office as soon as they begin working to ensure that staff with the appropriate working status look after people using the service. 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. DS0000019191.V343082.R01.S.doc Version 5.2 Page 8 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 DS0000019191.V343082.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home’s assessment process ensures that positive outcomes are achieved for people using the service and the facilities provided meet individuals’ diverse needs. EVIDENCE: The needs of prospective residents are assessed prior to admission to ensure that the home is able to meet individuals’ needs before offering them a placement at the home. Unit managers or the general manager would normally undertake pre-admission assessments. Wherever possible prospective residents would be invited to visit the home to meet staff, view the facilities and have any questions or concerns answered. Case tracking confirmed good practice. It was noted that one particular resident that was admitted from hospital needed to be on a ventilator for six DS0000019191.V343082.R01.S.doc Version 5.2 Page 10 hours daily. The manager explained that prior to the individual’s admission to the home all trained nurses had spent time working along side the hospital staff to ensure that they would be fully equipped and skilled to provide the specialist care required to meet the individual’s needs. Staff spoken to were able to describe the specialist one to one care that they were providing to the individual. Further discussions with staff about the pre-admission process it was established that staff were working closely with a particular resident with special needs and the relative to understand the individual’s needs and to ensure that the placement would be successful. The support manager said that for all admissions a member of staff is allocated to provide one to one attention to individuals on the day of the admission to support them to feel comfortable in their new surroundings and to enable them to ask questions about life in the home. This ensured that the assessment process would achieve positive outcomes for people using the service and the facilities provided meet individuals’ diverse needs. Senior managers were confident that within the last twelve months the home had been proactive by reviewing and distributing the service user’s guide and welcome pack to all new residents. A copy of the terms and conditions of occupancy had also been issued to individuals prior to admission. The home does not provide intermediate care. DS0000019191.V343082.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Care documentation reflected a more person centred approach of caring. The home has systems in place to ensure that the health and personal care of people using the service is based on their individual needs and that they are treated with respect and their right to privacy is upheld. EVIDENCE: It was noted that the home had reviewed its care plan documentation to reflect a more person centred approach of caring. Four care plans were examined and they contained detailed information to allow staff to care appropriately for individuals. Risk assessments relating to falls, moving and handling, tissue viability, nutrition and smoking were seen in the plans examined. There was evidence to indicate that plans were reviewed monthly to reflect changes in individuals’ care needs. DS0000019191.V343082.R01.S.doc Version 5.2 Page 12 Staff spoken to were able to describe how they helped to develop care plans. Comments within the surveys stated that the standard of personal care was very good. The following comments were noted: ‘The home provides very good care appropriate to the particular resident concerned.’ ‘The home looks after basic needs.’ All residents are registered with a general practitioner (GP) who visits the home as and when required. The home has its own physiotherapist and aromatherapist and has access to a range of health care professionals including practice nurses, the chiropodist, optician, speech therapist, dentist and the tissue viability nurse. On the day of the inspection the optician was visiting the home and several residents had their annual eye checks. Health care professionals who responded to the Commission’s comment cards said that the home ‘always’ seek advice and act upon it to manage and improve individuals’ health care needs. It was noted that one particular resident’s weight had not been checked since admission because the individual was not able to weight bear. It is recommended that the home should invest in the appropriate scales to allow staff to maintain an accurate record of the individual’s weight. The home uses a monitored dose medication system. There were no unexplained gaps noted in the medication administration record (MAR) sheets examined. The controlled drug register was checked and tablets in stock corresponded with records. It is recommended that staff should record their full signature and not initials in the controlled register to ensure that entries and signatures are clear and legible. A prescription form was observed on a clipboard in Gleneagles unit. The practice of leaving prescriptions on clipboards should be reviewed to minimise any potential risk of loss. Trained nurses spoken to said that the clinical manager regularly assessed their competencies. There is a system in place to ensure that MAR sheets are audited weekly by the unit managers and monthly by the clinical manager. Residents reported that their privacy and dignity were respected and staff were observed interacting with residents in a courteous and sensitive manner. Health care professionals and relatives who completed comment cards were confident that residents’ privacy and dignity were ‘always’ respected. Individuals’ preferred term of address was recorded in care plans seen. Residents’ attire was clean and tidy with attention to detail. Where residents had chosen to share a room, screening was provided to ensure that their privacy was not compromised when personal care is given or at any other time. In one particular shared room on Gleneagles unit the screening was slightly on the short side and could pose a risk of the individuals’ privacy being compromised. This was pointed out to the manager who agreed to make some adjustments to the screening. DS0000019191.V343082.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There are a variety of activities within the home to ensure that people using the service have a range of opportunities to participate in stimulating and meaningful activities. Meals provided are of a high standard, wholesome and appealing and are served in pleasing surroundings. EVIDENCE: The home employs two full time activity co-ordinators, two part time activity co-ordinators, a qualified music therapist, an aromatherapist and a hairdresser. There is an active resident committee group that meet on a regular basis and make a contribution to the activities provided. The weekly activity programme was displayed in the home for residents to be aware what was taking place. One particular resident spoken to said that over the last twelve months she had deteriorated and could no longer use her feet to do anything. However, thanks to the music therapist she was able to put her writing skills to good use by writing various songs and she had acquired a new outlook on life, which had given her strength to keep going. Over the course of a year she created a DS0000019191.V343082.R01.S.doc Version 5.2 Page 14 series of songs written about the seasons as she experienced them for her window. She taught several of these songs to the choir in the home of which she is a longstanding member. It was noted that many of the other members in the choir are people with dementia and it was found that they took great pleasure in learning something completely new. They responded to the nostalgia in the songs. The music therapist was spoken to and said that the choir arose out of individual and group music therapy sessions. Residents were now benefiting from the individual structures provided by music. The songs were also performed by a local choir in a concert at a church in the local community. The home has a mini bus that is used to provide regular trips in the community. Outside entertainers are booked to perform to residents to enhance the in-house activities. Those residents who wish to continue practicing their chosen religion were supported to do so to ensure that their spiritual needs were met. Residents are consulted about the home’s garden. A buddy service is available to those residents who wish to invest in more dedicated one-to-one service. The manager said that some of the younger residents were planning to hold a party and had approached her to discuss ground rules in relation to alcohol consumption and noise levels. She was pleased about their decision to discuss ground rules and felt that they were being responsible. The home encourages residents to maintain contact with family, friends and the local community. Visitors are welcome at anytime. Community groups visit the home for various activities and events. Accommodation can be provided subject to availability for those relatives wishing to stay overnight. One particular resident spoken to confirmed that her daughter is able to spend weekends with her and she is made to feel welcome. Visitors spoken to during the inspection said that they were made to feel welcome and tea-making facilities and refreshments were available throughout the day. Residents are encouraged to exercise choice and control over their lives. They are encouraged to handle their own financial affairs for as long as they are able to and have the capacity to do so. Staff make residents and relatives aware of the advocacy service that is available to offer advice on issues regarding care and financial support. They are also made aware that they can bring personal possessions with them to personalise their rooms. The quality of the food provided and the presentation of the meals are of a high standard and there is a choice of dishes and special diets are catered for. Alternative choices were available if residents did not wish to select from the main dishes. A large number of residents have meals in the main restaurant on the ground floor where hostesses serve them. Some residents choose to have meals in their bedrooms and are provided with a tray service. Others choose to have meals in the dining area of their unit. Private dining can also DS0000019191.V343082.R01.S.doc Version 5.2 Page 15 be arranged for visitors, special occasions and celebrations. Staff were available to offer assistance in eating to individuals discretely and sensitively. Residents confirmed that they were happy with the quality and quantity of the food and it was tasty. The menu on the day of the inspection reflected a good choice of starters, main courses and desserts. It was noted that the home had achieved the award for hospitality assured and fine dining. The manager said that residents are consulted about the menus. The home celebrates national days and events through the dining experience and regularly holds theme parties where residents can sample food from other countries. Drinks snacks and fresh fruits were available throughout the day to supplement midmorning refreshments, afternoon and evening tea. DS0000019191.V343082.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are able to express their concerns and have access to an effective complaints procedure. There are policies and procedures in place to protect them from any potential abuse. EVIDENCE: The home has a complaints procedure, which is available to residents and was on display in the home and summarised in the service user’s guide. Residents and relatives spoken to said that they knew how to make a complaint and the home was responsive to complaints. The home has a complaints folder and records of concerns and complaints were recorded and appropriately maintained. The manager reported that there had been a reduction in the number of formal complaints. To date the home had not received any formal complaints and any concerns or issues that had been raised were resolved to all parties’ satisfaction. Prior to this inspection The Commission had received a concern relating to an equality issue amongst the staff team. This was shared with the manager during the inspection. Although she was disappointed about the concern because as a good practice she was operating an open door policy to ensure that residents, relatives and staff could approach her about any matter she agreed to investigate the concern. Staff spoken to during the inspection confirmed that they had undertaken one to one training in customer care and felt that they were treated fairly by DS0000019191.V343082.R01.S.doc Version 5.2 Page 17 management. It was noted that training in equality and diversity for staff was being arranged. No allegations of any suspicion or evidence of abuse or neglect had been reported to the Commission about the service since the last inspection. Discussions with staff regarding their understanding of the safeguarding adult procedure confirmed that they had undertaken training. On the day of the inspection a further training session on safeguarding vulnerable adults had taken place. Staff were aware of what action should be taken if they suspected or witnessed a resident being abused. A copy of the protection of vulnerable adults policy was available to staff on all the units. DS0000019191.V343082.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service live in a safe well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home is located in very pleasant grounds adjacent to a golf course about two miles from Chalfont St Peter. The interior environment is of a high standard and is well maintained through a well- managed programme of refurbishment. The grounds are set in rural surroundings and the gardens are well maintained. Residents are involved in the ongoing improvement of the gardens and day-to-day activity and planting. The middle floor accommodates two of the three-dementia units and the physical disability unit. The ground floor has the third of the dementia unit and the unit for older people. There is a lift access to all floors. Each unit has a living and dining area and there is a conservatory on the ground floor. DS0000019191.V343082.R01.S.doc Version 5.2 Page 19 The three dementia units have pictures and objects of times past which are linked to the organisation’s memory lane programme. All bedrooms have en suite facilities and are provided with attractive furniture. Residents are encouraged to personalise their rooms. Some bedrooms seen were personalised with personal furniture, family photographs and mementoes that reflected the characters of individuals. Those residents whose care was case tracked were issued with specialist equipment and aids that they required to maximise their independence. Communal bathrooms seen were fitted with grab rails and hoists to meet individuals’ diverse needs. All areas of the home were clean and tidy and free from offensive odours. The laundry area was equipped with washing machines with the specified programming ability to meet disinfection standards. Arrangement for the control of infection was satisfactory. One member of staff was observed wearing gloves inappropriately whilst transporting a resident in a wheelchair. The unit manager addressed the issue with the member of staff. Residents, relatives and health care professionals who responded to the Commission’s comment cards said that the home was ‘always’ fresh and clean. The following additional comments were noted: ‘The home provides a safe caring environment’. ‘There is always a warm, friendly, environment.’ ‘The home creates an atmosphere of peace and calm.’ DS0000019191.V343082.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that staff are trained skilled and appropriately vetted to care for people using the service diverse needs. EVIDENCE: The home employs a multi-cultural staff team and reported at the time of this inspection it had twenty-nine trained nurses, seventy-eight care staff and forty-five ancillary staff. The manager was confident that the staffing numbers and skill mix of staff were appropriate to meet the diverse needs of residents. Residents’ needs are assessed twice yearly or as and when required and the staffing levels are reviewed to meet the assessed needs. It was noted that the home was providing one to one care to some individuals. Health care professionals and relatives who responded to the Commission’s comment cards said that staff ‘always’ or ‘usually’ have the right skills and experience to support individuals’ social and health care needs. The following additional comments were noted: ‘Some staff have difficulty with speaking/understanding English.’ ‘Staff are always happy to help.’ It was noted that ten staff hold the national vocational qualification (NVQ) in level 2 or above and six were working towards achieving it. Some of the care staff were qualified nurses in their country of origin but were not eligible to undertake adaptation and were working as senior carers. DS0000019191.V343082.R01.S.doc Version 5.2 Page 21 The recruitment records for five staff members were examined. All staff had completed an application form. PoVA first checks and criminal record bureau clearances had been obtained along with two written references. Statements of terms and conditions of employment were also issued. On one file there was not a recent photograph to confirm proof of identity. It was noted that some staff members needed to register with the home office under the A8 Worker Registration Scheme and had not done so. It is recommended that A8 workers should apply to register with the Home Office as soon as they begin working and within one month of starting work at the latest. All new staff receive induction training and ongoing supervision according to their level of experience to enable them to do their jobs well. The home has a dedicated trainer who is also supported by trainers from other departments. The training records examined indicated that all staff were receiving mandatory training updates and other specialist training on a rolling programme basis to meet residents’ basic needs. To date thirteen staff had completed the Alzheimer’s society Yesterday Today and Tomorrow training and further training dates were being arranged. Staff on the dementia unit had undertaken Memory Lane Training and person centred care. The manager said that staff had received one to one training in the new care plan documentation and in customer care. Training in equality and diversity was being arranged to ensure that staff would be confident in promoting equality and diversity. DS0000019191.V343082.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Temporary management arrangements are meeting the needs of the service and should ensure that people using the service health, welfare and safety are protected and promoted. EVIDENCE: The home does not have a permanent registered manager and at the time of the inspection a support manager and the organisation’s deputy operations director were managing the day-to-day running of the home. It was noted that a home’s manager had been recruited and a starting date was imminent. The support manager is a qualified nurse with many years experience of managing care homes and holds the registered manager’s awards. She said DS0000019191.V343082.R01.S.doc Version 5.2 Page 23 that she operated an open door policy and welcomed comments and suggestions from residents, relatives and other stakeholders. There was evidence that regular staff and residents’ meetings were being held, which provided opportunities for good communication and feedback about the service. There is a systematic self-monitoring system in place, which is achieved through an audit of an area of activity each month. This may include medication, customer service, infection control, health and safety or care documentation for example, care plans. The home conducted an annual quality assurance survey in June and was in the process of developing an action plan from the outcome of the survey to improve on the service delivery. Regular regulation 26 visits take place by a senior manager from the organisation and copies of the reports were on file to evidence that visits had taken place. A health care professional who responded to the Commission’s comment cards said that the service ‘works very well with clients and family, is supportive, always listens to family views, concerns and acts appropriately.’ Staff spoken to during the inspection seemed happy working at the home and felt that they were fairly treated by managers. Staff said that supervision was happening regularly and an appraisal system was in place. The home does not manage money on behalf of residents. Invoices for incidentals are sent to families. Examination of a sample of health and safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for residents. It was observed during the tour of the building that a bedroom door on the ground floor and the activity room on Gleneagles unit door were wedged open. It is required that doors must not be wedged open to ensure that residents are not at risk in their environment. DS0000019191.V343082.R01.S.doc Version 5.2 Page 24 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 DS0000019191.V343082.R01.S.doc Version 5.2 Page 25 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 OP38 Regulation 13(4)(a) Requirement Doors must not be wedged open with obstacles and doorstoppers to ensure that people using the service are protected from avoidable risks to their health and safety in their environment. Timescale for action 31/08/07 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 2. 3 4. 5 Refer to Standard OP8 OP9 Good Practice Recommendations The service should invest in the appropriate scales to allow staff to maintain and record the weights of people using the service who are not able to weight bear. When administering controlled medication to people using the service staff should record their full signature to ensure that entries and signatures are clear and legible. The practice of leaving prescriptions on clipboards should be reviewed to minimise any potential risks to people using the service. A recent photograph should be held on all staff members’ files to confirm proof of identification. The service should ensure that carers from within the DS0000019191.V343082.R01.S.doc Version 5.2 Page 26 OP9 OP29 OP29 European Union apply to register with the home office as soon as they begin working to ensure that staff with the appropriate working status look after people using the service. DS0000019191.V343082.R01.S.doc Version 5.2 Page 27 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 DS0000019191.V343082.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!