Inspection on 12/10/05 for Chaltonholme

This inspection was carried out on 12th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chaltonholme 18/09/07

Chaltonholme 01/03/06

Chaltonholme 17/03/05

Chaltonholme 07/10/04

Chaltonholme 29/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Chaltonholme 1-3 First Avenue Westcliff On Sea Essex SS0 8HS Lead Inspector Mrs Michelle Love Unannounced Inspection 6th October 2005 08:30 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 Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chaltonholme Address 1-3 First Avenue Westcliff On Sea Essex SS0 8HS 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) 01702 346534 The Southend on Sea Darby & Joan Organisation Ms Lisa Marie Brewerton Care Home 33 Category(ies) of Dementia - over 65 years of age (33), Old age, registration, with number not falling within any other category (33) of places Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Home may provide care for two residents under the age of sixty-five years whose names are known to the Commission for Social Care Inspection. 17th March 2005 Date of last inspection Brief Description of the Service: Chaltonholme is a large established home providing 24 hour care and accommodation for up to 33 older people. In addition the home is also registered to admit those people who have a formal diagnosis of dementia. Chaltonholme is owned by the Southend Darby and Joan Organisation. The home is situated in Westcliff on Sea and within close proximity to the local railway station, Southend shopping centre and a range of community facilities. There are 31 single and one shared bedrooms. The premises have been created by joining two main properties. Each floor is serviced by two passenger lifts. There are two communal lounges and one large dining area for residents. There is a large well maintained garden to the rear of the property and car parking facilities to the front of the premises. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by Michelle Love, inspector. The inspection lasted approximately seven hours. As part of the inspection records and documents were looked at, both residents and staff were spoken with and a tour of the premises undertaken. Following the last inspection to the home, nine statutory requirements and two recommendations were highlighted. Four of the nine statutory requirements and one recommendation were addressed. Those requirements and recommendations not met have been highlighted within this report. Since the last inspection the manager has been formally registered with the Commission. What the service does well: What has improved since the last inspection? The home’s care planning processes are much improved and clearly detail individual residents needs. Additionally accident records were seen to be detailed and included staff’s interventions. Since the last inspection the home’s staffing levels at night have been increased as a result of residents increased needs and because of the home’s layout. Some resident’s bedrooms have been redecorated and new carpet laid. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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 Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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): 3, 4 and 5 Prospective residents are assessed by the home prior to admission. It is unclear as to whether or not prospective residents and/or their representatives are given information and have the opportunity to visit the home prior to admission so as to make an informed choice as to whether or not Chaltonholme is a care home they wish to live in. EVIDENCE: Detailed and comprehensive pre admission assessments were available for the two newest residents to be admitted to the care home. In addition to these assessments a dependency profile was completed depicting the high, medium and low needs of individual residents. Information/assessments from placing authorities and/or local hospitals were readily available to enhance the pre admission process. No information was evident in relation to whether or not the resident and/or representative visited the home prior to admission. Staff training records evidence that several members of staff have undertaken and received training pertaining to mandatory/specialist courses related to the care and conditions of older people e.g. Basic Food Hygiene, Basic First Aid, Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 9 Medication, Health and Safety, Infection Control, Adult Abuse, Dementia Awareness, Safe Use of Bed Rails, Managing Incontinence and Pressure Area Care. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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, 9, 10 and 11 The care planning and risk assessment processes within the home ensure that residents health, personal and social care needs are clearly defined and set out within an individual plan of care. Medication systems within the home ensure that resident’s medication administration, record keeping, policies and procedures are safe and satisfactory. EVIDENCE: Four care plans were sampled on the day of inspection. On inspection all were seen to be detailed and comprehensive. In addition formal assessments were available pertaining to pressure sores, falls and moving and handling. Evidence was recorded detailing healthcare professionals involved with individual residents e.g. Consultant Psychiatry, GP, Dentist, Optician, Consultant Psychiatric Nurse, District Nurse Services etc. Risk assessments were also seen to be detailed and evidence suggested that both care plans and risk assessments are reviewed regularly and reflect changes to residents needs. Daily care records for residents were written daily and observed to be informative, identifying specific care given to residents by care staff and detailing how residents spend their day. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 11 Staff rapport between residents and care staff was observed to be good. It was evident from discussions with some members of staff that they had a good understanding of individual resident’s needs. It was positive to note that accident records for residents were much improved, and contained information detailing staff’s interventions. The home’s medication storage facilities, policies and procedures remain unchanged and appropriate. Several omissions were noted on the medication administration records whereby records were not signed by care staff to indicate that medication had been administered to and received by residents. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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): 12, 13 and 15 A programme of activities is available for residents. Arrangements for visitors are satisfactory. Residents receive a varied and appealing diet. EVIDENCE: All staff within the home participate and provide a range of activities for residents. Records were available detailing activities undertaken by individual residents. Care plan documentation detailed resident’s individual personal preferences, likes and dislikes relating to interests and hobbies. On the day of inspection no activities were seen to take place. Some members of staff were seen to sit within the lounge area and not engage socially or verbally with residents. Meals provided to residents were seen to be appealing and varied. Residents spoken with during the inspection were complimentary regarding the food provided. Residents are offered a choice of menu and alternatives are readily available. Following a recent visit by the local environmental health department, it was positive to note that all but one minor issue has been addressed. From discussions with the home’s chef it was evident that he had a very good understanding of individual resident’s requirements and needs. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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): 16 and 18 There is a complaints procedure and policy. The home has an adult protection procedure and policy and this ensure that residents are protected from abuse. EVIDENCE: Since the last inspection the home has received and investigated three complaints and received five records of compliments. Three records of complaint detailed the specific nature of the complaint and details of the investigation. No outcome following the investigation was available for one complaint. Two senior members of staff were able to evidence a good knowledge of adult protection procedures. Since the last inspection nine members of staff have received adult abuse training. The registered manager stated that three members of staff are to receive training in November/December 2005. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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 The home was clean, odour free and safe for residents. EVIDENCE: During the inspection one health and safety issue was highlighted relating to hot water emitting from a random sample of residents wash hand basins and two communal baths. Hot water was observed to emit from between 45.2° and 58.8° degrees centigrade. An immediate requirement notice was given to the home so as to address and rectify the situation as soon as possible and so that residents would be kept safe. Individual bedrooms were personalised and individualised. It was positive to note that some bedrooms had been redecorated and carpet replaced. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 15 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, 28, 29 and 30 Staffing levels within the home remain appropriate for the numbers and needs of residents. Some gaps were observed to indicate that robust recruitment procedures for newly appointed members of staff have not always been adopted. The home continues to be committed to providing appropriate training for all members of staff. EVIDENCE: It was positive to note that staffing levels within the home remain appropriate and suitable for the current needs of residents. Since the last inspection an additional member of night staff has been deployed. Care staff, receive appropriate days off duty and there has been a large reduction in the number of staff completing long days/double shifts. Since the last inspection seven new members of staff have been newly appointed. On most occasions all recruitment records as required by regulation had been sought but some gaps were noted pertaining to not all had a copy of a job description, one employees file evidenced that only one written reference was available, not all references were taken from their last employer and one persons Criminal Record Bureau check/POVA 1st check had not been received until after their start day. Induction records were available for the majority of new employees and these were seen to be detailed and comprehensive. Issues relating to training for staff have been addressed within the previous section of the report entitled `Choice of Home`. The registered manager is Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 16 currently completing NVQ Level 4 and two members of staff are undertaking NVQ Level 3. Two members of staff are currently undertaking NVQ Level 2 and three members of staff have completed NVQ Level 2. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33 and 36 The home is well managed. The registered manager demonstrates a clear understanding of residents/staff needs. Staff supervisions have been implemented but these are not as frequent or in line with National Minimum Standards recommendations. EVIDENCE: The manager has been formally registered with the Commission since the last inspection. The registered manager continues to evidence good leadership and management skills. Staff spoken with, were very complimentary regarding the management of the home. It was positive to note that the registered manager has a very good understanding and rapport with individual residents. On inspection of a random sample of staff supervision records, it was evident that supervision for staff has been implemented. The registered manager advised of the difficulties to undertake supervisions in line with National Minimum Standards recommendations. It was agreed with the inspector that Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 18 supervisions in the interim could be conducted quarterly. On inspection of Regulation 26 reports held within the home, the last report was dated March 2005. No further reports for the period April 2005-September 2005 were available. Reports are not forwarded to the Commission once monthly and they do not include details of staff/residents spoken with. Reports are seen to contain basic information. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 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 X X 3 3 3 X 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 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 2 X X Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that appropriate arrangements are made for the recording and safe administration of medication to residents. This refers specifically to omissions recorded on the MARS. (Previous timescale of 21.05.05 not met). The registered person must ensure that all parts of the home are so far as reasonably practicable free from hazards and unnecessary risks to the health or safety of residents are identified. This refers specifically to hot water emitting from wash hand basins/communal baths. The registered person must ensure that robust recruitment procedures are adhered to in line with regulatory requirements. (Previous timescale of 21.5.05 not met). The registered person must ensure that Regulation 26 visits cover all elements required within this regulation and a DS0000015424.V251053.R01.S.doc Timescale for action 01/12/05 2 OP19 13(4)(a) and (c) 01/12/05 3 OP29 17(2), 19, 01/12/05 4 OP33 26 01/12/05 Chaltonholme Version 5.0 Page 21 5 OP36 18(2) report is forwarded to the Commission once monthly. (Previous timescale of 1.7.05 not met). The registered person must ensure that all staff are appropriately supervised. (Previous timescale of 1.7.05 not met). 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP28 OP31 Good Practice Recommendations 50 of all care staff should attain NVQ Level 2. The registered manager should achieve NVQ Level 4. Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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 Chaltonholme DS0000015424.V251053.R01.S.doc Version 5.0 Page 23 - 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. 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