Inspection on 07/02/06 for Chalk Leys

This inspection was carried out on 7th February 2006.

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 24/05/07

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 Nichola Cahill Unannounced Inspection 7th February 2006 09:30 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.V281970.R01.S.doc Version 5.1 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.V281970.R01.S.doc Version 5.1 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 Manager.winglodge@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.V281970.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 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 long term care for up to thirty-seven older people. The home has four groups, each with a lounge and kitchen diner and a shared garden. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the annual unannounced inspection visit carried out on 7th February 2006 by Nicky Cahill (lead inspector) and Gill Gentles (inspector). The inspection commenced at 11.30 and was carried out over two and half hours. The inspection visit consisted of discussions with service users, a tour of the building, assessment against requirements made during the previous inspection and viewing of records regarding the health and well being of service users and staff training. A feedback of the inspection findings was delivered to the homes manager, Cheralyn Halvorson and the deputy manager. What the service does well: The home has a comprehensive service users guide in place. This will ensure that all service users are fully informed regarding the services offered by the home. Service users receive an in depth pre-admission assessment prior to being admitted to the home. This ensure that the home can appropriately meet the individual needs of the service users The home has developed good relationships with external health and social care professionals, ensuring that service users have access to a variety of health care services. The home is suited to its stated purpose and provides service users with a comfortable, homely and safe environment. Standards of cleanliness in the home are good. Service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. Staffing levels are appropriate to meet the needs of the current service user group. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 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.V281970.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 The home has a comprehensive service users guide in place. This will ensure that all service users are fully informed regarding the services offered by the home. Service users receive an in depth pre-admission assessment prior to being admitted to the home. This ensure that the home can appropriately meet the individual needs of the service users EVIDENCE: A comprehensive service users guide is issued to all service users as part of the homes admission procedure. A copy of this document was available in the front entrance of the home. Two pre-admission assessments were viewed. One assessment was for a service user admitted to the home prior to the inspection visit. This document was in depth and included all information pertinent to the needs at the time of the assessment. All information had been transferred to the care plan. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 9 The second document viewed was for a service user currently receiving an assessment. Due to the complex needs of this service user the manager and deputy manager had ensured that should the admission go head that they would be fully equipped with back up services from external health and social care practitioners to ensure that all needs were appropriately met. A trial visit to the home would be offered. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 The home has developed good relationships with external health and social care professionals, ensuring that service users have access to a variety of health care services. EVIDENCE: Two care plans were viewed. Care plans were well laid out and easy to read. Information recorded included essential information; action plans regarding individually assessed identified needs, manual handling assessments, risk assessments and nutritional assessments. Information recorded had been signed as agreed by the service user and/or a representative. However, some information did not include details of how a staff member would appropriately meet the assessed needs. Much of the documentation viewed mentioned that staff should ‘assist’ a service user but did not identify how. One service user was registered as partially sighted; however, no risk assessments were in place regarding this need. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 11 It is recommended that care plans are reviewed to contain more detailed explanations of how service users will be ‘assisted’ in their personal care. A review of risk assessments should cover all areas as required. Care plan documentation contained evidence of access to external health care services for individuals as necessary. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Core standards were assessed during the inspection visit in April 2005 and were being met at this time. EVIDENCE: Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Core standards were assessed during the inspection visit in April 2005 and were being met at this time. EVIDENCE: Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 The home is suited to its stated purpose and provides service users with a comfortable, homely and safe environment. Standards of cleanliness in the home are good. Service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: Chalk Leys is a home that was built in the 1960’s and currently provides services for thirty-six frail older people. The home has all single bedrooms, four lounge areas, each with its own kitchenette and dining room and a quiet room. The large garden is a pleasant area for service users to enjoy in the warmer months. From the brief tour around the home all areas appear to be well decorated and provide a comfortable, homely place for service users to live. Standards of cleanliness throughout the home were good and there were no offensive odours present. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 15 Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 Staffing levels are appropriate to meet the needs of the current service user group. EVIDENCE: The homes staffing rotas were viewed. Six care staff and one senior carer are on duty during the morning and five care staff and one senior are on duty during the afternoon period. The home has two waking night staff. It was discussed that the night staffing appeared to be low; this will be fully assessed during the next inspection visit against the assessed needs of the service user group. The care staff team are fully supported by the homes manager and deputy manager. The home has a number of housekeepers and kitchen staff on duty daily. The staff training file was viewed. Training in all areas, according to records viewed, was very low. Of the thirty-two staff employed only 16 had manual handling, 9 had been trained in first aid, 7 in food hygiene, 7 in medication practices and 9 in fire awareness. The manager reported that training provided by the organisation was difficult to access due to the large numbers of staff requiring the training over all of the homes in the area. However, it was discussed that if training was inaccessible Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 17 through the organisation on the scale required by Chalk Leys alternative arrangements must be made. It is a requirement that all staff receive training in all mandatory and specialist areas of care. Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Core standards were assessed during the inspection visit in April 2005 and were being met at this time. EVIDENCE: Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 19 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Chalk Leys DS0000022956.V281970.R01.S.doc Version 5.1 Page 20 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 OP30 Regulation 18 Requirement It is a requirement that all staff receive training in all mandatory and specialist areas of care. Timescale for action 30/04/06 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 YA7 Good Practice Recommendations It is recommended that care plans are reviewed to contain more detailed explanations of how service users will be ‘assisted’ in their personal care. A review of risk assessments should cover all areas as required. 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