Inspection on 27/06/05 for Chandos Lodge

This inspection was carried out on 27th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Chandos Lodge 08/01/08

Chandos Lodge 06/01/07

Chandos Lodge 03/12/05

Chandos Lodge 08/11/04

Chandos Lodge 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE CHANDOS LODGE 77 Stourbridge Road Hagley Stourbridge DY9 OQT Lead Inspector Andrew Spearing-Brown Unannounced 27 June 2005 08:05 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 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. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chandos Lodge Address 77 Stourbridge Road Hagley Stourbridge West Midlands DY9 OQT 01562 885858 01562 887291 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Chandos Lodge Limited Pearl Bartlett CRH 24 Dementia - over 65 Old age Physical disability - over 65 6 24 24 Category(ies) of DE(E) registration, with number OP of places PD(E) CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no other conditions of registration other than those refered to on the previous page of this report. Date of last inspection 8 November 2005 Brief Description of the Service: Chandos Lodge is a large, detached property situated in a semi-rural position on the main Stourbridge Road in Hagley. There are car-parking facilities at both the front and side of the premises. The home is registered to provide personal care for a maximum of 24 people over the age of 65 years who may also have a physical disability. The home may also accommodate up to 6 service users over the age of 65 years who have a dementia illness. Residents are accommodated on the ground and first floor of the premises in 18 single bedrooms and 3 double bedrooms. Ten of the single bedrooms have en suite facilities. A passenger lift is installed within the home. The home is managed on a day-to-day basis by a registered manager who is supported by an experienced registered provider. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken by two inspectors from the Worcester office of the Commission for Social Care Inspection (CSCI). The visit consisted of 5 hours inspection time. The last inspection at Chandos Lodge took place during early November 2004. The main focus of this inspection was therefore to assess the progress made in relation to the requirements from the previous inspection. On the day of this inspection the registered manager was on duty. Other staff on duty included a senior carer, a care assistant, a domestic and the cook. The owner was also present throughout the majority of this visiting. The manager and the owner were the only staff consulted during this visit. A small sample of residents and a visiting district nurse were also consulted. Many areas of the home were seen including some bedrooms and the majority of communal rooms and communal facilities. The care records of a sample number of residents were seen. Other documents seen included medication records, fire records and some training records. What the service does well: What has improved since the last inspection? Considerable improvement was noted in relation to the overall management of medication within the home since the previous inspection visit, although some additional improvement remains necessary mainly in relation to the storing of controlled medication. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 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. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 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 standard(s) 3 Information contained within the pre – assessment documentation was not sufficient to allow a care plan to be developed therefore placing residents at risk. EVIDENCE: The pre assessment document relating to a resident did not give specific information, which could be used to compile the initial care plan. The space available for recording information was minimum. Chandos Lodge is currently registered for a total of 24 residents; from this number 6 residents may have a dementia type illness. During this inspection it was evident that a number of residents did have a mental health illness although it was difficult to establish an exact number. Information obtained from staff differed as to the identity of residents with a dementia. The registered manager undertook to forward to the CSCI a list of residents, their care needs and the registration category under which they are cared for within the home. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 9 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 standard(s) 7 and 9 Care plans and risk assessments were insufficient and inconsistent in that they did not give the necessary detail regarding residents care needs to ensure that care staff are able to provide the level of input required. Chandos Lodge has made significant progress with regard to the administering and record of medication. EVIDENCE: The care plans of four residents were inspected as part of this inspection. The information within them did not always cross reference to other information held elsewhere. Terminology used such as ‘bed bound’ was used when this was not in reality the case. In addition although general instruction was given no indication as to how these instructions were to be achieved was given. Having conflicting information could lead to mistakes and does not demonstrate consistency in care delivery for example ‘alert’ and ‘drowsy and cat naps’ were recorded within the same persons care plan. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 10 Improvement in fall risk assessments is needed; one was noted to be unsigned as well as giving additional conflicting information such as ‘no real risk at present’ while elsewhere saying ‘has become unsteady.’ A visiting district nurse was confident that staff at Chandos Lodge take note of guidance and instructions given by them in relation to the care of a resident. There was a significant improvement in the overall management of medication since the last inspection. The previous months MAR (Medication Administration Record) sheets were viewed and were signed appropriately and filled out in line procedures. The care plan of one resident who self-administers medication contained a suitable risk assessment. The medication procedures need to be reviewed and made more specific to Chandos Lodge as they make reference to first level nurses as well as other senior staff, no nurse qualified staff are employed within the home as the registration is for personal care only. The wooden cupboard for storing controlled medication is not suitable in that it is not in accordance with the Misuse of Drugs Act (Safe Custody) Regulations 1973. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 11 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 standard(s) 12 Systems need to be in place to evidence that activities are suitable to residents needs. EVIDENCE: No records existed of any activities on offer to residents therefore it was not possible to assess there frequency, suitability or up take. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 12 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 standard(s) None of the standards in this section were assessed in any great detail as part of this inspection. As a result these standards will be assessed as part of a forthcoming inspection at Chandos Lodge. EVIDENCE: CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 13 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 standard(s) 19, 20, 22, 23, 24, 26 Although some areas of the home are acceptable other areas are in need of replacement or repair in order to provide an environment that is homely and safe to live in. EVIDENCE: The main lounge was comfortable in appearance however some areas were in need of improvement. The cushions on some of the chairs or settees did not match the actual chair. Furthermore approximately nine of the vertical drops on the blinds were missing. One bathroom is currently used for the sole purpose of cleaning commodes. A notice on display outside the dining room stated that commodes were ‘to be cleaned in bleach in bath’ on Mondays and Wednesdays. Two other bathrooms, one on each floor, are available for residents to bath. Bedrooms within the newer extension are fitted with an en-suite shower, therefore providing sufficient bathing facilities overall. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 14 No records regarding bath water temperatures were sought although assurance that fail-safe thermostatic controls are fitted was given. Covers were on the vast majority of radiators; as the weather was exceptionally warm on the day of this inspection no central heating was required and therefore radiator temperatures could not be established. A number of bedrooms were seen including all three double bedrooms. Those bedrooms seen were suitably homely and it was evident that residents are able to bring in personal items with them. A lockable piece of furniture was noted within bedrooms viewed although the availability of keys was not sought on this occasion. Bedroom doors had a suitable locking devise fitted although the mechanism was partly missing on the door of one bedroom. A bedroom carpet needs replacing, as does the corridor carpet leading out of the ‘library’ or quiet lounge on the first floor. The carpet on the main staircase is showing signs of wear and tear. Some bedroom carpets have ridges likely to be as a result of frequent shampooing and need either stretching or replacing. A piece of carpet in the library was loose and therefore presented a trip hazard, an immediate requirement was issued to secure this piece of carpeting. The top panel of the window in a bedroom was both damaged and broken and needs replacing. The dining room chairs appeared fatigued; one chair in particular was very badly stained. A chair was blocking fire escape in the dining room furthermore the fire door leading into the dining room was held open by a ‘hock and eye’ devise while the room was in use. Immediate requirements were made in relation to the fire doors. A passenger lift is in place to give easy access to the first floor. The lounge and a number of the bedrooms had pleasant views onto the wellmaintained garden. Part of the garden is easily accessible to residents, including anybody with limited mobility who wish to have a short walk or enjoy the warmer weather. Chandos Lodge was free of any offensive odours. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 An insufficient number of staff were on duty to meet the needs of residents when staff were engaged getting individuals up and dressed. This could potentially place residents at risk as certain periods of the day. EVIDENCE: Although raised as insufficient to meet the care needs of residents at the time of the last inspection the staffing levels remain at three carers including the registered manager throughout the waking day. Other staff on duty included a cook and a domestic. Upon arriving at 8.00 am it was noted that nine residents were sat in the dining room. It was later noted at 10.10 am that seven out of fifteen residents sat in the lounge were asleep. The manager stated that the two night staff commence getting residents up at 7.00 am. One resident was partly undressed in the lounge around breakfast time; no member of staff was in the vicinity to ensure that individual dignity was maintained. The small number of residents consulted stated that staff are very kind. A visiting professional described the staff as ‘excellent’. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 Insufficient recording regarding fire training at Chandos Lodge failed to demonstrate that residents and staff are free from risk. Some other documentation in relation to fire safety needs improvement. EVIDENCE: Care records were not secure as they were stored within an unlocked filing cabinet outside the dining room thus not preventing unauthorised access to information. The fire log was examined and showed that no staff training is documented as having taken place for any staff since February 2005 while other staff had no fire training recorded since June 2004. Following a recent report from a contractor the registered provider has recorded that it is considered that the emergency lighting in the home is sufficient in that ‘ they are all working’. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 17 No recent report from Hereford and Worcester Combined Fire Authority was available; a copy of this must be forwarded to the Worcester office of the CSCI. It was evident that the fire alarm is tested in sequential order on a weekly basis as required. The need for a new pin in the carbon dioxide fire extinguisher was recorded for a number of months; the registered manager believed that this was now done although the log did not confirm this statement. Not all the fire signage throughout the home was in line with the required regulation in that some were not pictorial. The accident records were viewed; some recorded incidents did not match up with information recorded within the care plans. Instructions as to how to lower the lift in an emergency were displayed. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 2 2 x x 2 x x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x 2 2 CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 19 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 3 Regulation 14 Requirement Written assessments completed before the admission of any service user in accordance with the requirements of Regulation 14 and Standard 3 must be comprehensive in terms of information content. (Previous timescale of immediate and on going not met). 2. 7 15 The service user plan must be detailed and provide clear and accurate guidance to staff on the actions to be taken to meet the changing personal and health care needs of service users. The falls risk assessment must contain accurate and details information in relation to the prevention of falls. A service-specific medication policy must be developed and implemented. (Previous timescale of 31/12/04 not met). immediate and on going Timescale for action immediate and on going 3. 7 13 (4) 15 (2) immediate and on going 31/07/05 4. 9 13 (2) CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 20 5. 9 13 (2) The cabinet currently used to store controlled medication must be replaced with one which meets the required standard. 31/07/05 this time scale is given to enable a suitable cabinet to be obtained. immediate and on going 6. 9 13 (2) Service users must have their medication reviewed by their GP when “as required” medication is administered on a regular basis. (This standard was not assessed as part of the inspection carried out on 27th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection) 7. 12 27 18 (1) (a) 31/08/05 Staffing levels within the home must be reviewed to ensure the routines of daily living and activities are flexible and varied to suit service users’ preferences and capacities, and to ensure the safety of service users within the home at all times. (Previous timescale of 31/01/05 not met). 8. 19 13 (4) 23 (2) (b) All areas of the home must be kept in good repair and good order. The carpet within the library must be must be secured to prevent the risk of a trip hazard. 31/08/05 9. 19 13 (4) immediate and on going CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 21 10. 20 24 23 (2) (c) Replace all fatigued and/or damaged items of furniture. (Previous timescale of 31/03/05 not fully met). 30/09/05 11. 21 13 (3) The arrangements for currently using a unused bathroom for cleaning commodes must be reviewed. Ensure that all hot surface temperatures are restricted to a maximum of 43ºC, or are safely guarded to prevent accidental injury through contact burns. (This standard was not assessed as part of the inspection carried out on 27th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 31/08/05 12. 25 12(1)(a), 23(2)(p) 28/02/05 13. 31 18 (1) (a) The provision of management hours must be reviewed to ensure that management time is suitable to the needs of the service. (This standard was not assessed as part of the inspection carried out on 27th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 31/03/05 14. 33 24 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 (The Care Homes Regulations 2001) and Standard 33 (National Minimum Standards – Care Homes for Older People) 31/03/05 CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 22 (This standard was not assessed as part of the inspection carried out on 27th June 2005. The timeframe previously set remains - this requirement will therefore be re- assessed as part of a future inspection). 15. 37 17 Residents care plans and other records must be held securly at all times. Accurate and up to date fire records training and fire safety records must be maintained. Fire signage must incororate a pictogram in line with the Safety Signs and Signals Regulations. A copy of the most recent fire officers report must be forwarded to the CSCI once it arrives at the home. Records regarding accidents must be accuratly cross referenced to information held within the care plan. immediate and on going immediate and on going 31/07/05 16. 38 23 (4) 17. 38 23 (4) 18. 38 23 (4) immediate and on going immediate and on going 19. 38 17 (1) (a) Schedule 3 (l) 17 (2) Schedule 4 (12) 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 19 Good Practice Recommendations Opportunity should be taken to forward a programme of decoration of the home to the Commission. This recommendation was not re assessed as part of this visit. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 23 2. 21 Consideration should be given to the decorative upgrade of communal toilet and bathing areas. This recommendation was not re assessed as part of this visit. CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 24 Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR3 7NW 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 CHANDOS LODGE E52 S18463 Chandos Lodge V228537 270605.doc Version 1.30 Page 25 - 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. 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