Inspection on 06/01/07 for Chandos Lodge

This inspection was carried out on 6th January 2007.

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

Other inspections for this house

Chandos Lodge 08/01/08

Chandos Lodge 03/12/05

Chandos Lodge 27/06/05

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 West Midlands DY9 0QT Lead Inspector Andrew Spearing-Brown Unannounced Inspection 6th and 12th January 2007 11:50 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 Chandos Lodge DS0000018463.V326082.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. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chandos Lodge Address 77 Stourbridge Road Hagley Stourbridge West Midlands DY9 0QT 01562 885858 01562 887291 chris.bradley@redwoodcare.co.uk 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) Chandos Lodge Limited Pearl Bartlett Care Home 24 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd December 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 residents over the age of 65 years who have a dementia type 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. A registered manager who is supported by an experienced registered provider manages the home on a day-to-day basis. The pre inspection information received by the Commission during September 2006 stated that fees at Chandos Lodge currently range from £336.00 to £373.00; the registered manager confirmed these figures during the second visit to the home. Additional charges are made for personal items such as hairdressing, newspapers and taxis. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector from the Worcester office of the Commission for Social Care Inspection (CSCI) carried out this inspection. The focus of any inspection carried out by the CSCI is to assess the outcomes for people who use the service. As part of the overall inspection of the service offered at Chandos Lodge two visits to the home were undertaken. The visits to the home were unannounced and lasted a total of 13 hours commencing at 11.55 a.m on the first visit and 10.00 on the second visit. The last statutory visit to the home, which was also unannounced, took place during November 2005. This inspection takes into account information received by the CSCI since the previous inspection as well as the visits to the home. Prior to the visit a pre inspection questionnaire was posted to the manager requesting certain information. The inspector received the completed document prior to the inspection. In addition to the pre-inspection questionnaire a number of questionnaires were also sent to the home for residents, relatives and other persons to complete. A total of 14 residents questionnaires, which appeared to be completed on behalf of residents by either staff or their family were returned to the CSCI prior to the inspection. None of these questionnaires were signed by neither the resident or included their name. In addition a total of 11 comment cards were returned from relatives / visitors and 2 from general practitioners. A partial look around the home took place concentrating primarily on communal areas and facilities. The care documents of a sample number of residents were viewed including care plans, daily notes, risk assessments and accident records. Other documents seen included medication records, some service records and some staffing records. The registered manager was on a day off during the first visit however other senior staff were available including the deputy manager who attended the home while on annual leave. The registered manager and the quality manager were present during the second visit to the home. In addition to the persons mentioned above discussions took place with two carers. Discussions took place with a number of residents throughout the inspection. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Although a number of concerns regarding the management and administration of medication became apparent as part of this inspection the majority of requirements from the previous inspection are now met. Improvements regarding the environment were noted especially the replacement of some carpeting. The replacement of dining room chairs continues to improve the dining facilities. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 7 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. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 4. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An assessment of care needs is carried out prior to admission although written confirmation of the homes ability to met identified care needs is lacking. EVIDENCE: Neither the service users guide nor the statement of purpose was viewed during this inspection; it was however noted that copies of these documents were displayed near to the front door. It is however likely that changes are required to the service users guide following amendments to the Care Homes Regulations, which came into force on 1st September 2006. In the event of any changes an amended copy of the service users guide should be sent to the local office of the commission. The file of a recently admitted resident contained an initial assessment as well as a document entitled residents record. The residents record comprised of Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 10 more details following the initial assessment document, together these documents are able to provide sufficient information if they are used to their entirety. The initial assessment seen was completed prior to the admission while the residents record was completed on the day of admission. Further comments regarding the care plan for a newly admitted resident appear within the next section of this report. The inspector saw no evidence that the registered manager confirms in writing that the home is able to meet identified care needs following assessment. Feedback from relatives upon the questionnaire was favourable regarding how well their relative settled into the home. Chandos Lodge is registered to care for up to six persons who may have a dementia type illness. The care of persons with a dementia type illness is specialised therefore making it necessary for staff to received suitable training in order that care needs can be met. The staff-training matrix demonstrated that the majority of staff have attended dementia awareness training, the only exceptions were some night staff and newly appointed staff. The contents of the training was not assessed. Chandos Lodge does not provide intermediate care and has no plans to provide such a service in the foreseeable future. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and associated risk assessments fail to fully support the care needs of residents placing them at potential risk. The provision of full and accurate documentation can assist in ensuring that care needs are met in a consistent manner. The management of medication needs some improvement to ensure that systems are safe. EVIDENCE: As part of this inspection a representative sample of care plans, risk assessments, daily notes and associated documents were viewed. The previous inspection report noted some progress in relation to care planning documentation. Despite the earlier improvement further improvements are required to meet the associated National Minimum Standard and ensure that care needs of residents can be fully met. Care plans need to be up to date and accurate to ensure that all aspects of health, personal and social care needs are identified and planned for. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 12 Each file viewed contained a range of documents including a sheet entitled ‘Daily Routine’ – which gave a brief pen picture of each resident. The daily records seen were generally sufficient in their detail regarding events which had occurred during each shift. However on a number of occasions no entry was made to evidence that concerns previously noted were followed up or actioned as necessary. The original care plans viewed of long stay residents were devised some time ago in one case April 2005. One care plan had some amendments recorded however as these were not dated it was not possible to determine when over the 21 month period these amendments had taken place. Monthly reviews of the care plan were recorded as having taken place. The associated standard says that care plans need to be reviewed on at least a monthly basis or more frequently to reflect changing care needs and current objectives. Monthly reviews did not however show any changes and continually recorded ‘no changes in care plan’. However events were noted on the daily notes such as an infectious condition and a need to elevate legs; both of these required a care plan. The monthly reviews of another care plan failed to capture information regarding a number of falls, caring for a chest infection or strategies for dealing with aggression. Involvement of residents in care planning was limited and needs to be improved. The care plan of a newly admitted resident also had shortfalls in that it failed to account for aggressive situations towards both residents and staff. Some risk assessments were in place however they were not up dated as necessary such as following a fall or other incidents within the care home involving an individual. No risk assessments are carried out to identify residents who are potentially at risk of developing pressure sores. Care plans were in place when pressurerelieving equipment was needed. It was noted that equipment such as cushions were used as detailed upon the care plan. It was suggested that further information is required regarding nutritional risk assessments including a need to standardise whether imperial or metric weights are used as care plans contained a mixture of both. Although staff consulted had a good knowledge of the residents within the home the lack of up dated care plans potentially places residents at risk. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 13 Following the previous inspection a number of requirements were issued in relation to the management and administering of medication. As part of this inspection the storage and recording of medication was examined including the current months Medication Administration Record (MAR) sheets. There was a photograph of each resident to assist in identification when giving medicines. The majority of MAR sheets were found to be satisfactory. However a number of shortfalls were identified which need to be improved to ensure the safe management of medication. The MAR sheet of one resident had a signature in place when no medication was available in the home. On a second occasion upon the same sheet a carer had signed for medication and then crossed it out. On another sheet it was evident that the signature was over scored when it became apparent that it was not needed. It is important that sheets are only signed once the item is taken / administered / applied. It became apparent that one resident was prescribed a lengthy course of antibiotics, unfortunately the MAR sheet evidenced that for two days it was believed the course was finished when a further supply was held within the home. Some medication was prescribed on an as and when basis, therefore the use or non-use of medication is determined by staff. When medication is prescribed on this basis a care plan giving staff guidance and direction is required in order to ensure consistency in care provision. It was noted that when medication is prescribed on a variable dosage the actual amount given was recorded this is good practice and enables a drug audit to take place. An audit of one residents painkillers was undertaken and found not to balance by 6 tablets. Although it was recognized that each resident had their own supply of medication as necessary it is important to ensure that audits are correct to demonstrate safe management of medication. Information recorded on one MAR sheet about one drug differed to the information on the original container. Although medication is booked into the home any anomalies like this need to be picked up and addressed. As a full list of current medication is necessary the MAR sheet must be correct to ensure that the correct dose is given. Each of the MAR sheets viewed showed any known allergies; where none were known this information was recorded. Amendments to the MAR sheets were double signed as needed. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 14 It was reported that no controlled drugs (CD) are currently in use. It became evident that some discontinued drugs did however remain in the home as staff had omitted to return them to the supplying pharmacy. Controlled Drugs were not stored in a CD cabinet that meets The Misuse of Drugs Regulations (Safe Custody) 1973. The commission continues to strongly recommend that the present storage facilities are reviewed and improved. Other medication not used was recorded within the returns book however one drug recorded as not given upon a MAR sheet was not recorded within the returns book therefore making it impossible to carry out a full drug audit. Homely remedy agreements signed by medical practitioners were held with the MAR sheets. Although it is good practice to have such documentation they are in need of review as they currently list medication, which can not be administered by non-nurse trained staff due to the invasiveness required. No trained nurses are employed at Chandos Lodge. A previous inspection report required a service specific medication policy. The current policy and procedures were briefly viewed as part of this inspection. It was acknowledged within the procedure that trained staff (nurses) do not administer medication in homes such as Chandos Lodge. It was noted that factual inaccuracies were included in the procedure such as reference to a treatment room. Chandos Lodge does not have a treatment room. Following the recent guidance issued (Medical Device Alert 2006/066) from the Medicines and Healthcare Products Regulatory Agency (MHRA) on the use of lancing devices a discussion took place regarding such notifications. Although assured that the above alert was not applicable to Chandos Lodge due to them not using these devices it was highlighted that an improvement in evidencing that action is taken is required. The quality manager took a copy of the guidance for reference. The displaying of a ‘bath list’ in a public area was discussed regarding its appropriateness and the maintaining of residents privacy and dignity. No concerns were noted during the inspection regarding care practices carried out by staff. Residents were clothed appropriately taking into account the time of year and gender / cultural issues. No male carers are employed at Chandos Lodge. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The menu and activities need to be reviewed to ensure suitability and choice for residents. EVIDENCE: Visitors are able to visit at any reasonable time. Visitors are able to use communal areas such as the lounge or dining room as well as resident’s own rooms as they wish. Information regarding a local advocacy service was displayed near to the front door. Links with the local community are somewhat limited except at major religious festivals such as Christmas. A list of activities is displayed near to the main lounge. The events listed over the previous few days were signed off as having taken place; this was not the case for the weeks since the New Year. The list showed that an outside entertainer had visited recently. Care staff were seen leading one to one Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 16 activities with residents. Although care plans gave some details of social activities these could be improved. No record of resident involvement with the daily activities is held in order to evidence their meaningfulness and effectiveness especially regarding persons with a dementia type illness. It was reported that resident meetings take place however the minutes of the most recent meeting were not available for inspection. The cook from another home within the organisation is working as an advisor to the other homes including Chandos Lodge to improve the overall standard and choice available to residents. On the first day of this inspection the main mid day meal was shepherds pie and frozen mixed vegetables. The meal was plated up in the kitchen and then taken into the dining room upon a tea trolley. It was noted that all meals (except one) had similar portions of both the meal and gravy. The menu stated that 3 vegetables are to be provided of which 2 are to be fresh. A number of residents made comments to carers regarding the size of meal stating that it was ‘far too much’. A choice of sweets was offered including fresh fruit, one resident requested some cream (not originally offered), which was obtained. A discussion took place regarding meals and how they are served to residents. A choice of squash was offered at lunchtime. It was noted that drinks were served to residents in the lounge during the daytime between meals. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear and accessible complaints procedure in place. In addition the majority of staff have attended training in relation to adult protection. Together these areas assist in safeguarding residents. EVIDENCE: Chandos Lodge has a complaints procedure, which was displayed in the hallway. The procedure is clear and included the address of the Worcester office of the commission should anybody wish to raise any matters of concern with the regulator. In response to a question upon the quality assurance questionnaire forwarded to a sample number of relatives ‘ Do you know how to complain? ’ 100 stated ‘Yes’. Since the last inspection the commission has received one complaint in relation to Chandos Lodge. This complaint was sent to the registered provider to be investigated, who responded to the commission as requested. Although the complaints records were not viewed as part of this inspection the registered manager confirmed that the home had not received any other complaints regarding the service provided. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 18 The home has a procedure regarding the reporting of adult abuse. A copy of a recently issued booklet issued by the local authority was held with the procedure. A number of staff were consulted about the action they would take regarding actual or alleged abuse. The responses were generally satisfactory, although staff need to be sure of the action that needs to be taken should they be concerned or become aware of any actual or potential abuse. Some staff have not attended training regarding the safeguarding of vulnerable adults; this is scheduled for March 2007. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 19 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): Standards 19, 20, 21, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the standard of the environment have continued in order to provide residents with a comfortable place to reside where care needs can be met. EVIDENCE: The main lounge and a smaller lounge off it are comfortable and homely in appearance. As part of a previous inspection it was noted that some dining room chairs appeared worn out. It was pleasing to see that all but one table had new chairs accounting for about 80 of the chairs in that area. It was reported that the remaining chairs are due to be replaced in the future. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 20 A small number of bedrooms were seen. Those bedrooms seen were suitably homely and it was evident that residents are able to bring in personal items with them. Wardrobes viewed were suitably secured to the wall. The carpets in bedroom seen were suitable, it was reported that some carpets were replaced following the previous inspection. Some bedrooms have low windows; the glazing in these windows needs to be to BS (British Standards) 6262. No kite mark could be seen on the window viewed. Confirmation that the glazing is to the necessary British Standard should be sought. The carpet on the main staircase continues to show signs of wear and tear. A carpet in a corridor leading out of the library area was recently replaced. Some radiators remain uncovered. A requirement to ensure all hot surface temperatures are restricted to 43° C, or are safely guarded to prevent accidental injury through contact burns remains unmet. A passenger lift and other aids such as a bath hoist are provided. A former bathroom was since the last inspection converted into a sluice room. The sluice within this area is traditional and its appropriateness to meet needs of residents as well as ensure infection control need to be monitored. A bar of soap was located in one toilet as well as liquid soap. The floor in this toilet was stained. It is not possible to identify the location of bathrooms / toilets as the doors are the same as other doors. The provision of suitable identification on bathroom / toilet doors may be beneficial to persons with a memory loss. A container of air freshener was in a unlocked cupboard in one bathroom, the container was labelled ‘do not breathe vapour / spray.’ All hazardous items must be held securely. The quality manager handed to the registered manager a copy of a recently issued book upon infection control within care homes for reference. The home was seen to be clean and tidy. An offensive odour was however noted in one double bedroom; it was stated that the room was due to have the carpet steam cleaned. The mattress in one bedroom was badly stained with dried faeces. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures were found to have some short falls, which could potentially place residents at risk. A review of staffing levels especially around tea time needs to take place to ensure that suitable and sufficient numbers are on duty at all times in order that care needs are able to be met. The number of qualified carers employed within the home is commendable. EVIDENCE: The current weeks staff rota was on display near to the dining room. The rota demonstrated that four persons including the manager are on duty each morning in addition to catering / domestic staff. The domestic member of staff used the vacuum cleaner in the hallway during lunchtime, which was appropriate in that it was an ideal time to have the flex out in a corridor while residents were eating. Staff working on the afternoon shift need to finish off the preparation of the residents tea. This brings about a couple of concerns and therefore needs to be reviewed: Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 22 A reduction in care staff available to care for residents while a carer is deployed in the kitchen both preparing the meal and cleaning up afterwards Infection control and cross infection concerns if persons carrying out personal care tasks also carry out tasks within the kitchen. Two wakeful carers cover the night shift. The rota showed that some day staff also undertake some night shifts, no member of staff appeared to be working excessive hours. A number of favourable comments were made regarding the staff from residents consulted during the inspection as well as by relatives on the feedback cards. ‘The staff are friendly, kind and cheerful.’ It was reported that twelve carers, hold an NVQ (National Vocational Qualification) level 2. The training matrix shows that two carers also hold a level 3 NVQ. This number of qualified carers is in excess of the National Minimum Standard as it equates to 75 as opposed to the 50 expected. Chandos Lodge needs to be commended for achieving this level of qualified cares. The company has recently introduced a new induction-training programme, which is believed to be in line with the standards set by Skills for Care. As this programme has not yet commenced with any employee at Chandos Lodge it will need to be assessed as part of future inspection visits. The staff records of three recently appointed employees were looked at. These files were generally satisfactory and evidenced some areas of good practice in relation to recruitment. It was noted that both a PoVA (Protection of Vulnerable Adults) first check and a CRB (Criminal Records Bureau) disclosure are taken up. Application forms and contracts of employment were held on file. Areas requiring some improvement were discussed at the time of the inspection as follows: The PoVA first of one employee was dated a couple of days after the employee concerned commenced work. The registered manager was confident that clearance was in place beforehand but this could not be evidenced. Although evidence of telephone references was in place written references were not in place prior to the commencement of employment. One person did not have a second written reference in place until 2 Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 23 weeks after the start of employment. Some references were written ‘To Whom It May Concern’. A training matrix was on display within the manager’s office. The quality assurance manager who had a good awareness of the training needs within the home held a more up to date copy of the matrix. A number of shortfalls in training were identified although the majority of staff have attended mandatory training. References to the shortfalls in training identified are included elsewhere within this report. A list of forthcoming training events across a number of homes in the organisation was on display including medication, health and safety and moving and handling. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has extensive experience and has recently obtained a management qualification. Staff supervision systems although in place need to be improved. The quality systems in place are good. Some health and safety matters including training need addressing, to fully safeguard residents. EVIDENCE: The registered manager is experienced in managing a care home for older people. A registered manager is required to hold two qualifications, one in management and one in care. The registered manager reported that she has recently completed the Registered Managers Award (RMA), which is a management qualification. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 25 Therefore the need to hold a care qualification to a level 4 NVQ remains and needs to be addressed. Both the certificate of registration and the certificate of public liability insurance were on display. Residents personal belongings are insured up to the sum of £500.00. The quality assurance manager has previously confirmed that both a business and financial plan are held at head office, which would be open to the commission, should they be required. It was reported that the home does not routinely hold money in safe keeping for residents preferring relatives to carry out this function. Expenditure occurred for items such as hairdressing is therefore invoiced to resident’s representatives. The National Minimum Standards state that care staff receive formal supervision at least 6 times a year. These sessions should cover: all aspects of practice philosophy of care in the home career development needs Although it was evident that supervision is taking place this was not as frequent for some staff as it was for others and needs to be improved. The recording of supervision was spread across a number of different documents making a full audit difficult. The quality manager has carried out an extensive review of the service offered a cross a number of services where she had management responsibilities including Chandos Lodge. The document applicable to Chandos Lodge was not viewed however the overall findings showing identified shortfalls were as well as the action taken to date. The organisation regularly carries out surveys amongst residents, relatives / representatives and GP’s to gain feedback regarding the level of service offered within the home. The results of these questionnaires are made available and were on display. The majority of the comments received were favourable. The responsible individual is required to visit the home on at least a monthly basis and prepare a written report to the manager. These reports were available and briefly viewed; no concerns were noted. The commission has received some notifications regarding events within the care home as required under Regulation 37, however a couple of situations when the commission should have been notified but were not were noted. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 26 As reported elsewhere within this report it was evident that some records are not sufficiently detailed or up dated to ensure effective and efficient care planning takes place. No policies and procedures other than the medication one were viewed during this inspection; these will form part of future inspections at Chandos Lodge. The fire records were viewed and demonstrated that fire drills and fire simulations take part of fire training; the extent of training provided needs reviewing as part of the risk assessment. The majority of staff received fire safety training during 2006 although some was prior to this date. The fire log was generally satisfactory it was however noted that information regarding fire extinguishers differed between the homes records and those prepared by the company who service equipment. The homes fire risk assessment had a date for reviewing as January 2007 and therefore needs to be done. Following the introducing of the Fire Safety Order towards the later part of 2006 the fire risk assessment needs to be reviewed taking the new order into account. As reported earlier within this report some shortfalls in training were identified including moving and handling. The previous report (November 2005) stated: ‘ A priority needs to be placed upon the training needs of night staff in relation to moving and handling and basic food hygiene.’ It was noted that two night carers have not received moving and handling training since 2003. An Environmental Health Officer (EHO) from Bromsgrove District Council visited during June 2006. A number of shortfalls were noted mainly regarding areas that needed to be cleaning as well as systems in place. The registered manager and the quality manager confirmed that these matters have received appropriate action. The temperature records regarding ‘fridge and freezers and hot food were satisfactory, although the sheets used latterly were not ideal. The sample of records regarding the safe maintenance of equipment and services were viewed. On the door of each bedroom / bathroom / toilet is a checklist showing water temperature checks and whether the window restrictor is in order. A number of concerns were discussed regarding water temperatures. 1. Some records evidenced that the hot water temperature particularly toilets is delivered at 50 º C. This is above the guidance given by the Health and Safety Executive. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 27 2. On some doors it was not evident whether the water temperature record was in relation to the bath or the shower. 3. Some areas were either not tested or not recorded during the last two months of 2006. The registered manager confirmed that window restrictors are in place. Although used for staff the upstairs office did not have restrictors and no risk assessment to demonstrate why they were omitted from the programme of fitting. As it is potentially possible for a resident to gain access it was agreed that they would be fitted. The inspector reminded the registered person of the importance of restrictors to safeguard residents. It was evident that the servicing of a hoist was to be expected imminently. The inspector was informed that the recommended work upon the passenger lift has taken place. A couple of unguarded radiators were noted. If these are used they need to be covered without further delay in order to safeguard residents from the risk of scalding. Accident records are maintained however evidence of care planning and risk assessment up dating following falls was not in place. Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 28 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 X X X 2 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 2 2 2 Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 14(1)(d) Requirement A letter confirming the homes assessment and the ability to meet care needs must be sent to potential residents or their representative. The registered manager must ensure that care plans are in place and up to date to ensure that care needs are identified and met. (This requirement replaces a previous requirement with a timescale of 03/11/05 which was not met. This requirement must be met without delay) The registered manager must ensure that risk assessments contain sufficient detail and kept up to date to enable care needs to be met. (This requirement replaces a previous requirement with a timescale of 03/11/05 which was not met. This requirement must be met without delay) When medication is administered to resident it must be clearly and DS0000018463.V326082.R01.S.doc Timescale for action 31/01/07 2. OP7 15 (2) (b) 31/01/07 3. OP7 13 (4) 14 (2) (a) 31/01/07 4. OP9 13 (2) 06/01/07 Chandos Lodge Version 5.2 Page 30 5. OP9 13 (2) accurately recorded. Any omission must be recorded and full drug audits must be able to be undertaken. A service-specific medication policy must be developed and implemented. (Previous timescale of 31/12/04 not met. A new and revised timescale is given) The provision of meals within the home must be suitable to the individual dietary needs of residents. All areas of the home including carpeting must be in good repair and suitable to the needs of persons within the home. Ensure that all hot surface temperatures are restricted to a maximum of 43ºC, or are safely guarded to prevent accidental injury through contact burns. (Previous timescale of 28/02/05 and 30/11/05 not fully met new timescale given) The registered persons must reviewing and monitor staffing levels in particular around teatime to ensure that care needs are met. Recruitment procedures must be robust as to safeguard residents. The registered manager must ensure that all staff undertake mandatory training. (Previous timescale of 31/01/05 not fully met - new timescale given) Cleaning products must be stored appropriately. The registered persons must identify and control risks including hot water and fire safety. DS0000018463.V326082.R01.S.doc 28/02/07 6. OP15 16 (2) (i) 31/01/07 7. OP19 23(2) 31/03/07 8. OP25 OP38 12(1)(a), 23(2)(p) 31/01/07 9. OP27 18 (1) 31/01/07 10. 11. OP29 OP30OP38 19 (1) 18 (1) 12/01/07 31/03/07 12. 13. OP38 OP38 13 13 (4) 06/01/07 31/01/07 Chandos Lodge Version 5.2 Page 31 14. OP38 37 The registered manager must ensure that events under Regulation 37 of the Care Homes Regulations 2001 are reported to the Commission. (Previous timescale of 03/11/05 and 30/11/05 not fully met new timescale given) 12/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard OP8 OP9 Good Practice Recommendations Standardise the information recorded on nutritional risk assessments to be either imperial or metric. It is strongly recommended that a Controlled Drug cabinet which meets the Misuse of Drugs Regulations (Safe Custody) 1973 is obtained. The cabinet in place does not meet the above regulation. The commission continues to strongly recommend Review the current practice regarding the serving of meals. Review the use of signposting within the home to assist persons with a dementia type illness. 3. 4. OP15 OP21 Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Chandos Lodge DS0000018463.V326082.R01.S.doc Version 5.2 Page 33 - 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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