Inspection on 08/01/08 for Chandos Lodge

This inspection was carried out on 8th January 2008.

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 06/01/07

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 Key Unannounced Inspection 8th January 2008 08:45 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.V349471.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.V349471.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 Ltd 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.V349471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th January 2007 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 the front of the premises. The home is currently registered to provide personal care for a maximum of 24 older people who may also have a physical disability. The home is also registered to accommodate up to 6 people over the age of 65 years who have a dementia type illness. At the time of this inspection building work was underway to increase the number of bedrooms. The building work was not complete and therefore the provider had not, at that time, made an application to have these rooms registered. Currently people using the service 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. Information upon the fee levels was not obtained as part of this inspection therefore the reader may wish to obtain up to date details from the care service. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality care. We, the Commission, carried out this inspection without any prior notice This inspection was undertaken over a period of two days. The manager was on duty throughout the time we spent in the home. The registered provider and the quality manager visited the home during our visit. Mrs Dorothy Stubbs, an expert by experience, was present for part of this inspection. An ‘expert by experience’ is a person who, because of their shared experience of using services, and /or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. This inspection takes into account information we have received since the last inspection as well as the visits to the home. During the inspection discussions were held with the above people, the deputy manager, a number of staff members, some people using the service and two visitors. We had a look around the home and observed what was happening. In addition we viewed the care documents regarding some people using the service such as care plans, risk assessments and daily records. In addition we viewed medication records, staff training records and recruitment records. At the time of our visit the home was accommodating 23 people including 1 person who was receiving respite (short stay) care. What the service does well: Information about the service is available to people. An assessment of care needs is obtained prior to somebody moving into the home. ‘I am very happy with the care given to my mother. She is settled and peaceful – always looks nice and can be visited at any time.’ ‘The staff at Chandos Lodge are doing a marvellous job’ People using the service looked well cared for. A range of activities are provided including entertainment. People consulted said that they enjoy the meals provided. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 6 Suitable recruitment procedures are in place to assist in safeguarding people. People residing within the home are able to personalise their own bedroom. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3. Standard 6 is not applicable. Quality in this outcome area is good Information is available for potential users of the service. Information regarding the care needs of potential users of the service is obtained prior to admission to ensure that needs can be met within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection we spoke to two people who were recently admitted into the home. Both people commented that they were happy in the home stating that it was very good. From information taken from the surveys we received prior to our visit everybody believed that they ‘always’ or ‘usually’ received sufficient information about the home. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 9 One relative wrote: ‘It was the visit and staff attitudes – positive – that made us choose this home. My xx also felt it was comfortable and welcoming.’ Information about the home was on display in the reception area. We saw information in relation to an individual recently admitted into the home as an emergency respite (short stay). The file contained basic information from the funding local authority. Due to the emergency situation a suitably trained person from the home did not have the opportunity to carry out his or her own assessment before the admission took place. An initial care plan was devised the day after admission, it is important under these circumstances that the initial plan is devised as soon as possible. Chandos Lodge does not provide intermediate care and had no plans to provide such a service in the foreseeable future. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate The home is able to meet the health and personal care needs of people using the services. Written documentation regarding people’s care needs, including both care plans and risk assessments needs to be improved to ensure that care needs are met consistently. Further improvements in the management of medication especially storage would ensure procedures are safe This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of our visit we viewed a number of care plans and other documents held in relation to a random number of people receiving a service. Although the documentation at Chandos Lodge has improved recently we found some areas where improvements are necessary to ensure that the health care needs of people are suitably assessed and monitored. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 11 Following a recent admission into the home on a respite basis an initial care plan was devised. The details within the initial care plan were in line with the information received from the funding authority. No further information had been added to the care plan during the stay in the home as staff became increasingly aware of care needs and how they could be best met. As a result the care documents did not provide staff with the strategies to ensure consistency in care delivery. On another file we saw a risk assessment regarding the use of bed rails. The assessment lacked detail to establish whether the risks of using equipment were fully considered prior to using it. We were informed that a general risk assessment covers all the beds within the home however the assessment needs to be specific to individuals to recognise differing care needs. We saw no evidence of routine checking of the bed rail and the care plan made no reference to staff checking that the equipment was safe. We saw an entry on the daily records regarding some unknown bruising on a persons body. This did not appear to be investigated and no care plan was in place regarding the prevention of bruising or the involvement of others if the person was prone to bruise easily. We were able to identify other care needs of individuals using the service by reading through daily notes where no care plan was in place. Risk assessments for matters such as falls, nutrition, moving and handling were in place however some lacked sufficient detail. Care staff were knowledgeable about the care needs of people however having a full detailed care plan in place establishes strategies to be implemented and guidance to staff in order that consistence in care delivery can be achieved. One relative wrote within our survey: ‘I can only say that they help my mother very well’ and ‘ Care and consideration would seem to be of utmost importance.’ We reviewed the management of medication. The majority of medication is held within a medicines trolley. The trolley was suitably secure and the deputy manager held the keys. The pharmacy carried out an audit of medication systems during December 2007 and completed a report. No concerns were noted within the pharmacy report. The manager carries out a weekly check of medication. The sheet completed on 07/01/08 showed that no discrepancies were found. We viewed the current Medication Administration Record (MAR) sheets and found them to be in generally in good order. The actual dose given when people are receiving a variable dose was not always recorded which would make a full drug audit difficult. Care plans need to make it clear how variable doses are determined so that individual staff do not have to make these Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 12 decisions without guidance. Other areas were completed as required such as the signing of medication into the building. We carried out an audit of a course of antibiotics and found them to be correct. The home had a small amount of medication, which needed to be managed as controlled drugs. The records were in order and balanced. The cupboard used for keeping controlled medication is however no longer acceptable as all care homes now have to comply with the Misuse of Drugs and Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007. During our time in Chandos Lodge it was noted that although staff were busy they found time ‘to chat’ to people using the service. Staff were observed transferring a small number of people using the service from wheelchairs in to armchairs. We noted that one transfer was conducted well with staff engaging in conversation with the person concerned. During another transfer staff did not appear to notice that their actions resulted in an individual losing their privacy and dignity. Although the incident was most properly unintentional it does nevertheless demonstrate the need to ensure that privacy and dignity is considered at all times. People using the service were suitably dressed taking into account gender and weather conditions. People consulted during this inspection stated that they are looked after very well. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 13 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 good Carers provide a range of activities and recreational opportunities for people. The home is calm and relaxed resulting in people being able to enjoy their day to day lives. People using the service are complimentary about the food served in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One relative commented upon a survey that ‘visitors are always welcomed ’ We saw a number of posters advertising events that were due to take place such as an exercise session and a sing along. We discussed with the manager that the posters appeared ‘busy’ due to the print used which made them unclear. We asked the manager to consider whether people with a visual impairment may have difficulty in reading information laid out in such a style. Our comments were taken on board as when we returned on a later date the format on posters was a lot easier to make out. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 14 A list of activities scheduled to take place was displayed however it was on a standard size piece of paper and could be difficult for some people to read. We were told that the list was primarily to act as a prompt for staff who would then verbally inform people of the days event. Activities listed included tiddlywinks, card games, knitting, puzzles, dominos and bingo. The list also included watching Songs of Praise on the television and outside entertainment such as the sing along and exercises. Library books are available for people to borrow. A hairdresser visits the home on a regular basis. A number of people were having their hair done on one of the days when we visited the home. People told us how much they enjoyed having their hair done. People using the service told us that they were happy with the service they receive and the activities provided. The Expert by Experience observed the serving of a mid day meal. The meal was served ready plated from the kitchen loosely covered with foil. The meal itself consisted of faggots, peas, cabbage, carrots and mashed potato. Gravy was served separately to those who wished to have some. We saw staff assisting people discretely. We were told that should people want an alternative meal this would be provided. Two different kinds of squash were available. People we spoke to said that they like the food. Two people told us that it was like living in a hotel. Minutes of a recent residents’ meeting stated that people were happy with the meals provided. A suggestion to have spaghetti bolognaise was made during that meeting. We also saw people having a morning cup of tea and biscuit from a trolley. We noted and brought to the manager’s attention that the member of staff carrying out this task served the biscuits by picking them up in her fingers rather than using tongs. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 15 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 People using the service have access to a complaints procedure. Staff are suitably knowledgeable about the action necessary to protect people from actual or potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure was on display within the entrance hall. The procedure needs to be clear that complaints can be made to the commission at any stage and not only in cases where a complaint is not ‘satisfactorily resolved’. The procedure needs to be amended to reflect the recent changes within the commission. The complains log held within the home showed that the service had received two complaints since our last visit. Both of these were in relation to lost clothing. It was recorded that the lost items were replaced. We have not received any concerns or complaints about the service provided at Chandos Lodge since our last inspection visit to the home. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 16 We have not received any allegation regarding actual or suspected safeguarding matters within Chandos Lodge. Staff members consulted were able to respond appropriately to questions asked of them regarding the protection of people against abuse Prior to new employees commencing duties at Chandos Lodge a check is made against the Protection of Vulnerable Adults (PoVA) list to ensure that people are suitable and therefore assist in safeguarding people using the service. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 17 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, 22, 24, 25 and 26 Quality in this outcome area is adequate The renewal of some fabrics would ensure that people using the service are accommodated in a comfortable environment. Some areas identified during this inspection need to be reviewed in order to full protect people from the risk of injury. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chandos Lodge is currently registered to care for up to 24 people. At the time of this inspection building work was taking place to the side of the home to increase the number of bedrooms. The registered manager was unsure of the actual proposed increase in bedrooms and other facilities such as communal areas and facilities. Following this inspection a brief outline of the proposal Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 18 was sent to us for information. An application to register this part of the home needs to be made once the work is completed. The main lounge and a smaller lounge off it are comfortable and homely in appearance although some of the chairs in the larger lounge are showing signs of wear and tear and some are marked in places. The hems on curtains in the larger lounge were torn. The quality of the television picture was poor and needed attention. We have previously noted that many of the dining room chairs have been replaced. It was previous reported that the remaining chairs were due to be replaced in the future however this has not as yet happened. It is envisaged that these will be replaced when new furniture is purchased to cater for the proposed increase in registration. Due to the current building work the view from the dining room has been removed. A number of people made comment about this and about the building work in general. A small number of bedrooms were seen. The bedrooms seen were suitably homely and it was evident that people using the service are able to bring personal items in with them. We have previously noted that wardrobes were suitably secured to the wall; we found one on this occasion that was not. We looked at the linen on one bed and found it to be very worn. The pillow was lumpy and the quilt cover was torn and stained. These matters were brought to the attention of the manager who undertook to get it sorted. The previous inspection report stated ‘some radiators remain uncovered’. It was believed that all radiators were now either covered or turned off. During our second visit to the service two radiators were noted along the first floor corridor without any cover in place. Both of these were hot, one was very hot. It was suspected that they were turned on due to a cold spell of weather. Action is necessary to assess this risk and make suitable arrangements to safeguard people from accidental scalding. We have previously mentioned the need to ensure that glass within low level windows or patio doors is safety glass in line with British Standards. The need to ensure safety is in case of accidental falling on to the glass and the risk of injury. A passenger lift and other aids such as a bath hoist are provided; service records were not viewed as part of this inspection. We previously reported that a former bathroom was converted into a sluice room. The sluice within this area is traditional and its appropriateness to meet the needs of people using the service as well as ensuring suitable infection control measures needs to be monitored. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 19 The flooring in one toilet was stained. The bulb had no light shade. As some toilets have a wooden seat it was questioned whether they can be suitably cleaned in line with infection control requirements. Toilets were cleaned during the time we spent in the home. The seat cover on a hoist over a bath was stained. Bathroom and toilet doors have some means of identifying them from other doors however more suitable identification on bathroom / toilet doors may be beneficial to persons with a memory loss. No grab rails were seen within the toilets to assist people who are less mobile use these facilities. Handrails are not in place along corridor areas. The lack of handrails needs to be assessed in the future as part of the monitoring of the home to ensure they are not required. It was noted that the stairs might present a problem to some people as there is only a handrail on the right hand side (going up) and at the bend of the stairs the rail ends until the corner is turned. The lack of handrails needs to be risk assessed in relation to the people using the service. No offensive odours were noted during this inspection. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 20 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): Standard 27, 28, 29 and 30 Quality in this outcome area is good Usually enough staff are on duty to meet the identified care needs of people using the service. Training is provided to enable carers fulfil their duties; gaps in training are known about in order that these gaps are filled. The number of staff undertaking training towards a recognised qualification should assist in improving service delivery. The recruitment procedures are sufficiently robust in order to safeguard people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff rotas were on display near to the dining room. These were viewed and the number of staff on duty was checked. On the second day of this inspection one carer had telephoned in sick earlier that morning. The registered manager arranged for the shift to be covered in order to ensure that sufficient staff were on duty. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 21 The rota demonstrated that four persons including the manager are on duty each morning in addition to catering / domestic staff. A relative wrote: ‘Staff always seem to be cheerful and keep the residents clean and comfortable.’ Another person wrote: ‘They are kind and caring.’ Since the previous inspection the registered provider has made provision to have staff working in the kitchen in order to finish off or prepare tea. Having staff working in the kitchen therefore ensures that staff are available to meet the care needs of people using the service. It was reported that currently ten carers, hold an NVQ (National Vocational Qualification) level 2. A carer who was due to commence work at Chandos Lodge in the near future also holds this qualification. It was reported that three carers also hold a level 3 NVQ. As a total of nineteen carers are currently employed at Chandos Lodge the number of qualified carers is just in excess of the National Minimum Standard as it equates to 53 as opposed to the 50 expected. Carers NVQ certificates were on display in the reception hall. At the time of the previous inspection it was reported that the company had introduced a new induction-training programme. It was believed that the training is in line with the standards set by Skills for Care. The registered manager stated that no new care staff had started since the introduction of this training programme therefore this area could not be assessed on this occasion. The staff documentation held regarding a newly appointed member of staff was viewed. The information seen was generally satisfactory and evidenced areas of good practice in relation to recruitment. A PoVA (Protection of Vulnerable Adults) first check had taken place. The full CRB (Criminal Records Bureau) disclosure was still awaited. The registered manager was aware that until a full CRB is held no employee can work unsupervised. Some conflicting information on different documents was brought to the attention of the registered manager who undertook to check the information. A training matrix was on display within the manager’s office. The quality assurance manager, who has a good awareness of the training needs within the home, completes a matrix on a monthly basis to ensure that it is up to date. The majority of staff have attended mandatory training, where shortfalls were identified the reason for the shortfall was known. The majority of staff Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 22 have received some training in dementia care however for some people this was some time ago. The organisation continues to provide training across their homes in the area therefore allowing staff to attend these events at a number of different venues. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 23 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 good An experienced manager is in place who ensures the home is managed in a way that respects the needs of people using the service. Quality systems are in place to safeguarding people and improve their quality of life. Some improvement in the management of supplies would further protect people from the risk of injury. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager who is experienced in managing a care home for older people has completed the Registered Managers Award (RMA); the certificate for this qualification was on display. As the RMA is a management qualification Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 24 the manager also needs to hold an NVQ qualification in care. The registered manager expects to commence upon this training as soon as possible. Both the certificate of registration and the certificate of public liability insurance were on display. The personal belongings of people using the service 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. These documents were not sought during this visit. The registered manager confirmed that the home does not routinely hold money in safe keeping for people using the service preferring relatives to carry out this function. Expenditure occurred for items such as hairdressing is invoiced to individual’s representatives. Records from 2007 evidenced that staff had, during that period of time, received regular supervision in line with the expectation within the National Minimum Standards. One member of staff consulted confirmed that she received regular supervision. The quality manager continues to carried out an extensive reviews of the service offered within Chandos Lodge. The document was viewed and detailed some areas where improvement had taken place or was needed in addition to areas where the home was complying with the National Minimum Standards. The registered provider makes regular visits to the home as required under regulation 26. Following these visits a report on the findings of the visit needs be submitted to the manager and this should be available for the purpose of inspection. Recent reports were not available although the registered manager confirmed that the visits had nevertheless taken place. The registered manager is aware of the requirement to notify the commission of certain events that may occur within the home. We are not aware of any incident happening when we were not notified accordingly. As reported elsewhere within this report it was evident that some records are not sufficiently detailed to ensure that effective and efficient care planning and risk assessment takes place. The registered manager and quality manager noted the shortfalls in order to make the necessary improvements to ensure that people using the service have needs met and are safeguarded. The fire records were briefly viewed and seen to be in good order. We did not view the fire risk assessment. A sample of records regarding the safe maintenance and servicing of equipment were viewed. On the door of each bedroom / bathroom / toilet is a Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 25 checklist showing water temperature checks and whether the window restrictor is in order. Although risk assessments were in place we were concerned about high water temperatures and the potential risks. This matter was discussed with the registered manager. Some records evidenced that the hot water was delivered at temperatures at over 70 °C. These temperatures were reduced by the time we visited again as the temperature of the boilers had been reduced. The provider undertook to seek advice regarding how to best manage water temperatures within the home while ensuring that other health and safety matters are also taken into consideration. We previous identified one window where a window restrictor was not in place; this was however in an area used by staff. Due to the building work this part of the building was no longer in use. The suitability of window restrictors needs to be continually assessed for appropriateness. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 X 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 3 3 3 2 2 Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 (1) Timescale for action Ensure that the care plan of each 30/06/08 person using the service sets out in detail the action, which needs to be taken by care staff to ensure that all aspects of health and personal care needs are met. Appropriate and detailed risk assessments, which are in line with identified care needs must be in place. Risk assessments must be regularly reviewed to ensure the health safety and welfare of people using the service. The storage of medication classed as ‘controlled’ must be in line with legal requirements in order to fully safeguard against potential risks of having such items within the building. A full and detailed risk assessment must be undertaken regarding remaining uncovered radiators and appropriate action taken to reduce the risk of DS0000018463.V349471.R01.S.doc Requirement 2 OP7 13 (4) (c) 30/06/08 3 OP9 13 (2) 31/07/08 4 OP25 13 (4) (c) 30/06/08 Chandos Lodge Version 5.2 Page 28 potential injury to people using the service. 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 3 4 5 6 Refer to Standard OP15 OP16 OP19 OP21 OP22 OP38 Good Practice Recommendations The proposed review regarding the serving and keeping meals hot should continue. The complaints procedure should be reviewed to reflect that complaints can be referred to the CSCI at any time. The fabric and fittings throughout the home should be fit for purpose. A review of signposting within the home to assist persons with a dementia type illness should take place. A risk assessment should be undertaken regarding the handrail on the staircase. Suitable action should be taken to ensure that people who use the service are protected at all times by controlling the temperature of water delivered to wash hand basins. Chandos Lodge DS0000018463.V349471.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands Regional Office Paradise Circus Queensway Birmingham B1 2DT 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.V349471.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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