Inspection on 24/05/07 for Chalk Leys

This inspection was carried out on 24th May 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

Chalk Leys 08/03/10

Chalk Leys 10/03/09

Chalk Leys 07/02/06

Chalk Leys 20/01/05

Chalk Leys 05/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Chalk Leys London Road Great Missenden Bucks HP16 0BB Lead Inspector Chris Sidwell Unannounced Inspection 24th May 2007 11:30 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 Chalk Leys DS0000022956.V331626.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. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalk Leys Address London Road Great Missenden Bucks HP16 0BB 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) 01494 863051 01494 890224 manager.chalkleys@fremantletrust.org Manager.ladyelizabeth@fremantletrust.org The Fremantle Trust Cheralyn Halvorson Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Chalk Leys is one of a number of homes run by the Fremantle Trust in Buckinghamshire. The home is located in Great Missenden, within walking distance of the village centre. The home provides care for up to thirty-seven older people in single rooms. No rooms have ensuite facilities. The home is divided into four groups, each with a lounge and kitchen diner and a shared garden. General Practitioners (GP’s) from two local surgeries visit on a regular basis. Other health care services such as, district nurse support, podiatry, dentistry, opticians, physiotherapy and occupational therapy are available through the home and the GP’s surgery. At the time of the inspection the fees ranged from £370 to £491 pounds per week. Additional costs include chiropody, hairdressing, newspapers and personal items. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of three days and included a six hour unannounced evening visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit, a questionnaire was sent to the manager with questionnaires for distribution to service users, relatives and visiting professionals. Five residents, seven family members and one general practitioner returned the questionnaires. Residents and families were also spoken to on the day of the unannounced visit. Discussions took place with the manager and care staff. Care practice was observed and the care of three residents followed through in detail. A tour of the premises and examination of records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well: The assessment process works well and potential residents and their families have information about the home to help them decide whether their needs can be met, before they decide to move permanently. The personal, healthcare and medication needs of people who live in the home are met during the day. One lady said who had come from hospital said that ‘they have got me back on my feet’. Another said that it was the ‘best move she had made’. The needs of those nearing the end of their life are met with the support of the local palliative care teams. Routines are flexible and residents are encouraged to adopt the lifestyle that would prefer. The standard of meals is high and residents’ nutritional needs are met. Meals were a sociable occasion and the chef goes out of her way to offer meals that residents would like. The complaints and protection policies and procedures work well, giving residents and their families’ confidence that their concerns will be addressed. The Commission for Social Care Inspection has not received any complaints about the home and has not been notified of any allegations made to the local authority. There are sufficient, well-trained and suitable staff to meet residents’ needs in the daytime. The staff were observed to be caring and respectful towards residents. One resident said that ‘they will do anything for you’. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 6 The Fremantle Trust is an experienced care provider and an experienced manager manages the home. There are quality assurance and health and safety systems in the home to improve the quality and safety of care offered. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The assessment process works well and potential residents and their families have information about the home to help them decide whether their needs can be met, before they decide to move permanently. EVIDENCE: The care of three residents was followed through in detail, one of whom was staying at the home to provide respite for her daughter who was the main carer. Their care files showed that the home manager had assessed them before they moved to the home. There was also information available from the care manager and the hospital where the resident had moved to the home from hospital. The assessment documentation prompted staff to ask about specific needs relating to religious and cultural needs. All the residents and family members who returned the questionnaires said that they had received enough information about the home before they moved in and one said that she had had the opportunity to stay for a trial period. The manager said that Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 9 some residents came for respite care initially and decide to stay or choose the home when they decide to move permanently. The home does not offer intermediate care. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The personal, healthcare and medication needs of people who live in the home are met during the day. The needs of those nearing the end of their life are met with the support of the local palliative care teams. There is a need to ensure that care needs can always be met at night if resident’s care needs are high. EVIDENCE: The care of three people was looked at in detail and a number of other care files examined. All files held care plans. Not all had been signed by the resident or their family, although those who returned the questionnaires and who were spoken to on the day of the visit said that they had been asked about the care that they wanted. One resident had moved to the home recently for respite care. Her initial care plan had been developed from her pre-assessment. She had complex needs due to mobility problems and had fallen twice during the night, although had not come to any harm. Her care plan identified her risk of falls although a detailed plan was not in place at this moment. A number of residents living at the home had cognitive loss although Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 11 this had not been their primary need when they moved to the home. The personal hygiene needs of all those who could not manage this themselves had been met and residents were well dressed and warm and had had their hair dressed. This is important to promote peoples self esteem and well being. The care plans had evidence that the general practitioner visits regularly and that people who live in the home have access to the optician and chiropodist. Moving and handling risk assessments had been undertaken. Falls risk assessments had been undertaken. Residents are weighed regularly and the weights of those people whose care was looked at in detail had remained stable since they moved to the home. All residents seen had drinks within reach throughout the day of the visit. The residents spoken to said that they saw the doctor regularly and the families spoken to said that they were kept informed if their family member was unwell. They were all pleased with the care that they received. The General Practitioner who returned the questionnaire said that staff had an understanding of residents’ care needs and that his specialist advice was incorporated into the care plan. He felt that medication was appropriately managed. There are medication policies and procedures in place. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. The carer spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision the doctor and family would be informed and a way forward agreed. The training records showed that all staff who administer medication have had training and have been supervised until their competence has been deemed satisfactory. The staff had however been administering medication from a dosette box provided by a relative for one lady who was on respite care. This is not good practice. Examination of past medication records for residents who had stayed at the home on respite care showed that this was not normal practice and that medication is normally administered from a pharmacy dispensed blister pack system or from the original box dispensed by the pharmacist. One resident was receiving palliative care and his and his family’s needs were being met sensitively with the support of the palliative care team. There are only two members of staff on at night and there had been difficulty meeting his needs the previous night. The manager contacted the operational manager and was able to agree an additional night staff to meet his and the other residents needs on a short-term basis. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Routines are flexible and residents are encouraged to adopt the lifestyle that would prefer. The standard of meals is high and residents’ nutritional needs are met. EVIDENCE: There is an activities coordinator in post, who works 15 hours a week. On the day of the unannounced visit to the home, three residents were going to local lunch club, a quiz was being held in one lounge and a group of residents were watching and enjoying a daytime television programme about the elderly in another. An activity schedule was displayed which showed that a range of activities was available every day of the week. The hairdresser was in the home and a number of residents were enjoying having their hair done and a cup of tea ‘under the dryer’. The residents who returned the comment cards said that they enjoyed the atmosphere in the home and could join in if they wished. They said that they had a choice as to how they spent their day. Families spoken to said that they were welcome at any time and were always called when necessary. Residents are helped with their personal care in their rooms and the GP who returned the questionnaire said that he could always see his patient in private. The statement of purpose states that visitors are Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 13 welcome at any time and that the home supports residents to remain in contact with family and friends. The meals are of a high standard. All the residents who returned the questionnaires said that they enjoyed the food. There was evidence from minute of residents meetings that residents have input into the menus. A choice of main course is offered. On the day of the unannounced visit several residents who did not like either choice were offered alternatives. The food is home cooked and meals are spread throughout the day. One lady spoken to said that ‘she was never hungry’ and looked forward to mealtimes. Mealtimes were observed to be a sociable occasion and aids, such as plate guards and adapted cutlery, were available to help residents maintain their independence. Carers were seen to be helping those who were unable to eat unaided, discretely and sensitively. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints and protection policies and procedures work well, giving residents and their families’ confidence that their concerns will be addressed. EVIDENCE: There are complaints policies and procedures in place. A complaints log is kept and action was seen to be taken in response to concerns and complaints. All the residents who returned the questionnaires said that they knew who to speak to if they were unhappy. The family members who returned the questionnaires said that they were aware of the complaints procedures although none had had occasion to make a complaint. One family member said ‘I had a problem and spoke to the home’s manager and it was dealt with immediately’. The home is aware of the local multi agency strategy for the Protection of Vulnerable Adults and staff have had safeguarding training. Those spoken to said that they would have no hesitation in reporting any concerns to the manager. The Commission for Social Care Inspection has not received any complaints about the home and has not been notified of any allegations made to the local authority. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. In general residents live in a safe, clean and wellmaintained environment. Their rooms are personalised and residents said that they liked living in the home. EVIDENCE: The home was built in the 1970’s and is in reasonable state of repair. However no rooms have ensuite facilities and most rooms have old-fashioned commodes on show. There are outline plans for the home to be reprovided on another site with upgraded facilities in the future. There are gardens, parts of which are attractive and well kept and some of which need improvement. Residents’ rooms were homely and in a good state of repair. Many residents had chosen to personalise their rooms and bring some of their own furniture. The home was spotlessly clean and the staff were aware of infection control procedures. The housekeeper was proud of her role in preventing cross Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 16 infection. There are infection control policies and procedures in place although these have not been updated since November 2003. These should be updated in line with the latest guidance provided by the Department of Health in June 2006. There were no offensive odours in the home and staff were observed to wash their hands. There are paper towels in all residents’ rooms for the use of staff and liquid soap in some. Where it is considered not advisable to have liquid soap in residents rooms the staff carry sachets of soap for their own use. Alcohol hand rub is available. The laundry was well-organised and soiled linen and clothing was dealt with appropriately. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 17 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 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient, well trained and suitable staff to meet residents’ needs in the daytime however the staffing levels at night should be reviewed to ensure that their night care needs can also be met. EVIDENCE: There is as an experienced staff team and a staffing rota is kept. There are additional staff at busy periods of the day and the residents said that their needs were met. There are sufficient ancillary staff during the day to maintain the home in a clean and hygienic way and to ensure that there are no unpleasant odours. On the day of the unannounced visit however there were insufficient staff to meet residents’ needs at night. The home was providing palliative care to one gentleman. He had been very restless the night before and had fallen from his bed. Another resident on respite care had also fallen. The night record book recorded a number of restless residents over a period of time and a number of residents who needed personal care due to incontinence during the night. In addition to their care duties and regular checking of all residents throughout the night, the night staff are also expected to undertake cleaning of communal areas, shampoo carpets if necessary and keep the laundry going. The organisation, as a matter of urgency, must ensure that there are sufficient staff to meet residents’ care needs at night. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 18 The records of four members of staff were looked at. All had evidence that the required checks as to suitability had been undertaken prior to the new staff member starting work. All had two references and a ‘POVA’ first or full Criminal Records Bureau Disclosure. Interviews had taken place and records had been kept. They did not all have an up to date photograph of the staff member, which should be addressed. There is an induction programme in place although the manager said that the first date available for new staff might be some months after they had started. The organisation should ensure that there is sufficient capacity on the induction courses for staff to attend in a timely way. Seventy-three percent of staff hold the National Vocational Qualifications in Care at Level 2 or above, meeting the standard that fifty percent of care staff should hold this qualification. Staff have had training in the basic mandatory topics and some had had additional training in infection control, dementia care, report writing and understanding difficult behaviour. The training records were up to date. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 19 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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An experienced manager manages the home and there are quality assurance systems in place to improve the quality of care offered to residents in response to their wishes. EVIDENCE: There is an experienced manager in post who has achieved the Registered Managers award. The staff spoken to said that the atmosphere was open and that their input was valued. There are clear lines of accountability with the organisation’s central management team. Residents and staff are involved in the running of the home and minutes of staff and resident meetings are held. There are regular staff meeting with the Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 20 Fremantle Trust, which include discussion of the forthcoming developments and the implications for residents, and staff. An annual development plan is developed for the home and despite the fact that it is to be rebuilt some minor refurbishments have been made. The home has implemented a quality assurance system, which involves a regular audit of the quality of the service. This was last undertaken in October 2006. The Fremantle Trust Chief Executive undertakes regular quality assurance visits and copies of the reports written following the visit are kept on file in the home. The home has systems in place to manage the personal allowance of residents if they wish and records and receipts are kept of any expenditure made on their behalf. There are health and safety policies and procedures in place and generic risk assessments to promote safe working practices have been undertaken. The training records showed that staff have had the basic mandatory training in health and safety topics such as moving and handling, food hygiene and health and safety. The pre inspection questionnaire showed that the maintenance of equipment and services is up to date. Fire training has been held and the necessary checks of fire equipment had been undertaken on a regular basis. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 21 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP27 Regulation 18(1) (a) Requirement Timescale for action 31/07/07 2 OP29 18(1)(b) The organisation must review the night staffing levels to ensure that resident’s care needs can always be met at night. Staff files must contain an up to 31/07/07 date photograph of the employee. 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 OP26 Good Practice Recommendations The organisations infection control policies and procedures should be updated in line with the latest guidance provided by the Department of Health in June 2006. Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 23 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 Chalk Leys DS0000022956.V331626.R01.S.doc Version 5.2 Page 24 - 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!