Inspection on 02/03/06 for Chandos Lodge Nursing Home

This inspection was carried out on 2nd March 2006.

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 Nursing Home 04/06/07

Chandos Lodge Nursing Home 12/06/06

Chandos Lodge Nursing Home 16/08/05

Chandos Lodge Nursing Home 03/03/05

Chandos Lodge Nursing Home 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Chandos Lodge Nursing Home Blackpond Lane Farnham Common Bucks SL2 3ED Lead Inspector Mr Guy Horwood Announced Inspection 2nd March 2006 09:40 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 Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chandos Lodge Nursing Home Address Blackpond Lane Farnham Common Bucks SL2 3ED 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) 01753 643224 Mr Hayatt Mrs Hayatt Halimah Halkier Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Elderly Physically Frail Elderly Mentally Frail (Organic) Date of last inspection 16th August 2005 Brief Description of the Service: Chandos Lodge Nursing Home is located in a quiet residential area of Farnham Common. The village centre is a short distance away, and has a small selection of shops. The towns of Slough and High Wycombe are a short distance away and possess a larger selection of shops and other amenities. The home itself is relatively isolated from public transport networks, although rail and bus links are to be found at nearby Slough and High Wycombe. The home has recently undergone extensive refurbishment to improve facilities and in order to increase the number accommodated from 24 to 31. Residents will be accommodated in one of 29 single rooms or 1 shared room. 16 rooms possess en-suite washbasin and toilet facilities, and there are additional bathrooms and shower rooms on both levels of the home. Bathrooms and shower rooms facilitate disabled bathing, and grab rails are fitted throughout. A through floor lift enables access to the first floor of the home, and hoists are provided to facilitate safe moving and handling practice. The home has a large dayroom, which provides space for meals, activities, receiving visitors and relaxing. A team of nurses, carers, catering and housekeeping staff, supports the homes manager and proprietors. A qualified nurse is to be found on the premises twenty-four hours a day. All Service Users are registered with a local General Practitioner, who attends as requested, and other healthcare professionals can be contacted either directly or by G.P referral. The homes providers, Mr and Mrs Hayat, are very much involved in the daily running of the home, and following the departure of the previous manager in December 2005, Mrs Hayat has decided to apply to be registered as the homes manager. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the announced inspection carried out at Chandos Lodge Nursing Care Home on the 2nd March 2006, between the hours of 9.40am and 2.45pm. The lead inspector was Mr Guy Horwood who was accompanied by Mrs Rosemarie James, Regulation Manager. The inspection consisted of touring the premises, meeting with residents and staff and viewing records and documents pertaining to the provision of care and the running of the home. At the time of the inspection there were 24 residents accommodated at the home. The home’s previous registered manager, Mrs Halkier, left her post in December 2005. The home’s proprietor, Mrs Hayat has decided to take on the position of manager, and is looking to appoint a senior nurse to manage clinical /nursing issues. Mrs Hayat is in the process of submitting her application to be registered as required under the Care Standards Act 2000. Mrs Hayat was present throughout the inspection, and along with her husband received feedback at the conclusion of the visit as to the inspector’s findings. From this inspection it was apparent that Mr and Mrs Hayat and the homes entire staff team, with support from external agencies, have worked hard to address issues identified through the previous 12 months inspections. They are to be commended on their hard work and the significant improvements attained, and it is anticipated that their desire to provide a caring and homely service will continue. The inspectors found staff polite and helpful and would like to thank them for their hospitality, co-operation and assistance during the inspection. The inspectors would especially like to thank the residents for their time and for allowing the inspectors into their home. What the service does well: A number of visiting relatives were spoken with during the inspection. Comments received included: - “We cannot fault the care our sister gets”, - “They (staff) are all very nice here”, - “It’s excellent here”. Visiting relatives also informed the inspectors that they are always offered drinks when visiting or meals if they visit near mealtimes. Relatives spoken Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 6 with who were visiting their mother were very complimentary about the home and stated, “They were going to book a room”. Their relative had decided to stay at Chandos Lodge following a period of respite care at the home. Staff appear caring and kind and residents appear well cared for. Staff show an awareness of a variety of residents cultural and religious needs. Staff have developed positive links with visiting healthcare professionals. Residents are able to receive visitors at times of their choosing; receive a choice of meals and where to dine; are able to follow religious observance; are provided with some entertainments and activities. It was noted that staff, where required, assisted residents with their meals in a kind, considerate and unhurried manner. The improvements and refurbishment of the premises, along with the standards of cleanliness within the home, have created a pleasant and homely environment for residents to live in. The home is staffed with sufficient staff numbers to meet resident’s needs, and staff are receiving the opportunity to undertake training pertinent to their role. What has improved since the last inspection? Pre-admission assessments are completed to a satisfactory standard. Care plans were found to be complete, up to date and provided good detail as to care needs and how these were to be met. Medication is received, recorded, stored, and administered safely, and residents receive their medication as prescribed. Meals and drinks are provided in sufficient amounts; are of a good standard; incorporate relevant dietary needs, likes and requests; and therefore provide residents with appealing meals and meal choices. Recruitment procedures protect residents. The management of the home promotes resident focused care, and ensures residents health, personal and social needs are catered for in a pleasant, caring and homely environment. Significant improvements have been made with regards to health and safety training and monitoring within the home, thus the health, safety and welfare of residents and staff is promoted. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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 Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Pre-admission assessments of potential residents are conducted, and this allows the home to make an informed decision as to whether they can meet a residents needs, and as a consequence, residents appear to be placed appropriately. EVIDENCE: The pre-admission assessments for two recently admitted residents were viewed. These showed significant improvement since the last inspection, with assessments completed fully and containing relevant details and supporting evidence from external agencies. Assessments were signed and dated by the person completing them, and identified where the assessment had taken place. It is anticipated that this standard of the assessment of potential residents will be maintained. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Service Users health care needs are documented in care plans. These care plans are orderly, working documents, are up to date and subject to review and auditing. This ensures residents current identified needs are known to staff to enable them to provide the appropriate care. Staff appear to be caring and residents appear to be well cared for. Residents have access to healthcare professionals external to the home to ensure that their healthcare needs are met Medication is received, recorded, stored, and administered safely, and residents receive their medication as prescribed. Access to residents care records by external healthcare professionals should be consented to by residents to ensure that confidentiality is respected. EVIDENCE: Through the tracking of specific care provision for 2 recently admitted residents, 2 care plans were viewed. It was evident that this aspect of record keeping within the home had been reviewed and reformatted since the last Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 11 inspection, although the format retained the use of both pre-printed and individually written records. Evidence was noted of the care plan having been discussed with not only the resident, but also their relatives. It was noted that a General Practitioner had signed one care plan to say that they had viewed it’s content. It is strongly recommended that the consent of the resident be obtained and recorded before the care plan is shared with people other than their Next of Kin and the homes care staff. Care plans were found to be orderly, user friendly and were stored securely. The level of information included in these records had improved significantly since the previous inspection, as had the detail pertaining to the care to be provided to meet individual residents needs. A record of when individual care plans had been audited and reviewed was noted. Assessments pertaining to moving and handling, nutrition and risk assessments were satisfactory, and records of visits by healthcare professionals complete. A record of activities provided to individual residents is included in care plans. Despite the significant improvements seen in care planning and record keeping within the home, Mrs Hayat stated that further work is required to improve care records, and that she is dedicated to maintaining a high level of record keeping by all levels of staff. Mrs Hayat stated that she has had, and has arranged more, training and support with regards to care planning from external agencies. A review of care planning will be undertaken at the next inspection, although Mrs Hayat and the staff team are to be commended on the improvements to date in the care planning system within the home. Residents, whether cared for in bed, sitting in their bedroom or the lounge, appeared well cared for and comfortable. Pressure relieving mattresses were seen in use on beds, and pressure-relieving cushions were noted in use for several residents in the lounge. It is recommended that the settings for pressure relieving mattresses be recorded for individual residents in their care plans and/or on their beds. In bedrooms records were being maintained as to the frequency of turning residents in bed and the provision of drinks. Relatives spoken with stated that they are contacted by the home if the resident becomes ill, and any contact with the General Practitioner is relayed to them. Staff attempt to cover residents catheter leg bag’s discreetly where worn, and in keeping with the residents attire. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 12 The homes procedures pertaining to the receipt, storage, handling, administration and recording of medication within the home was reviewed. The senior nurse detailed how the home now used Intercare to provide residents medication, and how they had been supported by a representative of this organisation to review and improve medication practice within the home. - Medication was stored securely. - Medication administration records, (MAR charts), were up to date with no gaps noted. MAR charts were well maintained and any reasons for the omission of medication were clearly noted. - Where staff entered instructions on charts, supporting documentation of the original prescription was held with the MAR chart. - A copy of the resident’s original repeat prescription was found to be held with each MAR chart. - Evidence of review of medication by residents General Practitioner’s was present. The overall practice of handling medication within the home had been vastly improved upon, to the point that this standard is now considered as met. This has been achieved through the support of Intercare, and the efforts of staff, who are to be commended on this achievement. It is anticipated that this standard will be maintained. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Residents are able to receive visitors at times of their choosing; receive a choice of meals and where to dine; are able to follow religious observance; are provided with some entertainments and activities. Residents are presented with choice within everyday routines. Meals and drinks are provided in sufficient amounts; are of a good standard; incorporate relevant dietary needs, likes and requests; and therefore provide residents with appealing meals and meal choices. EVIDENCE: Mrs Hayat stated that she has liased with Age Concern who are looking into projects with local schools. An advocacy service has visited the home to see 2 residents and it is hoped that they are to return to see another 2 residents. Resident’s religious preferences are recorded in care plans, and a priest has been organised to visit the home in March for the first time. Mrs Hayat stated that entertainers visit the home and that regular social events are held including fetes and barbeques. Mr Hayat possesses a licence enabling him to drive a bus. This was undertaken 2 years ago and is in order that the home can take residents on trips throughout the year. In the past 12 months residents have been on day trips to the seaside and to see the Christmas lights in London. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 14 The inspectors were informed that a residents meeting has been organised for the 9th March 2006 and a relatives meeting is planned for after Easter. Several visitors were spoken with during the inspection, and confirmed that they could visit at any convenient time of the day. They also confirmed that they were contacted where their relative became unwell. A new chef has been appointed to the home in a permanent position. The chef had been placed at the home by an agency and as a result took on the permanent position. Records were seen to show that a relevant food hygiene qualification had recently been updated, and that COSHH training had been undertaken on the 27th February 2006. It is recommended that the chef undertake training specific to the dietary needs of elderly people and the provision of special therapeutic diets. Throughout the inspectors visit, residents were provided with regular hot and cold drinks, and in an attempt to introduce a wholesome and balanced diet, residents were offered a choice of fruit “smoothies” as a mid-morning drink. These were seen to be very popular with residents. Due to the home accommodating residents from a variety of cultural backgrounds, the homes menu incorporates a variety of dishes. Lunch at the time of the visit gave good examples of the menu’s provision of choice, with residents able to choose from roast beef and vegetables, a halal meat curry and a vegetarian curry. Meals were served by care staff from a heated trolley, with due regard being exhibited to relevant health and safety guidelines. Residents were offered a choice as to where they received their meal, and were subsequently served either at dining tables or in armchairs with lap tables. All residents received drinks with their meals. The inspector was informed by visitors and staff that home made cakes are provided and are very tasty. It was noted that staff, where required, assisted residents with their meals in a kind, considerate and unhurried manner. In some instances staff were seen to stand over residents when assisting with their meals. Residents spoken with commented that their meal had been tasty and of the usual standard. The inspectors sampled the day’s lunch, which was found to be well presented, well cooked and tasty. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The home has a complaints procedure for residents and their representatives to express their concerns and expect a structured response. However, records with regards to complaints are not held in an orderly manner and may result in issues not being addressed appropriately and as per the homes procedures. Staff have not received up to date training with regards to the Protection of Vulnerable Adults and the identification and reporting of abuse, in order to ensure that staff are provided with the means to report such issues promptly and appropriately. As a result residents safety may be compromised. However, improvements in staff recruitment procedures do help to safeguard residents. EVIDENCE: The homes complaints procedure is displayed in all resident’s bedrooms. The home has received one complaint since the last inspection. At the time of the inspection Mrs Hayat disclosed a current complaint brought to her attention involving the loss of a residents property. Despite Mrs Hayat assuring the inspectors that she is investigating this issue and that she has liased with the residents family, records held in the complaints log were inadequate and were not signed by the person taking the initial details. The relatives involved in the above complaint were spoken with at the time of the inspection, and despite their issues pertinent to their complaint, expressed that they were happy with the care received by their relative at the home. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 16 Mrs Hayat stated that training with regards to the Protection of Vulnerable Adults and the identification and Reporting of abuse has not taken place. It is a requirement of this report that such training be given priority for all care staff, but is to also include catering and housekeeping staff. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The improvements and refurbishment of the premises, along with the standards of cleanliness within the home, have created a pleasant and homely environment for residents to live in. EVIDENCE: The home was found to be secure at the time of the visit, and entry to the home by visitors has to be enabled by staff members. CCTV monitors the front entrance to the building. Mrs Hayat stated that the external grounds of the home are to be tidied and made more attractive in the coming months. The home was found to be in excellent decorative order throughout, with high standards of cleanliness and no unpleasant odours detected. At the time of the visit the home was warm and comfortable. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 18 The home is furnished with lighting, carpets and curtains of good quality and a domestic design, and furnishings include resident’s personal property. All rooms have adjustable nursing beds, which are less than 12 months old, and these possess full-length integrated cot-sides. Windows open to provide ventilation, and windows above ground level are fitted with restrictors. The home possesses new hoists for the safe manual handling of residents. All rooms are fitted with a new nurse call bell system, and this was in working order at the time of the visit. Clinical waste bins were located throughout the home. Electric hand dryers are fitted within a number of bathrooms. Dispensers for hand sanitising gel were stationed at 12 points within the home, with Mrs Hayat stating that more are due to be acquired. Plastic apron dispensers are fixed at numerous locations throughout the home. Staff were seen to work with due regards to infection control measures – e.g., the use and disposal of gloves and aprons. The home has been fitted with a new industrial washing machine and tumble dryer. The washing machine has a sluicing facility. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. At the time of the inspection the home was staffed with a sufficient number of care staff to meet personal and healthcare needs. The homes recruitment policies and procedures have improved significantly and as a result residents are protected by the homes recruitment procedures and practices. Care staff are provided with frequent and relevant opportunities for training in order to meet resident’s personal, health and social care needs. EVIDENCE: At the time of the visit the home was accommodating 24 residents, and appeared staffed sufficiently to meet this number of residents needs. Usual staffing numbers equate to 2 trained nurses and 4 carers on an early shift, 1 nurse and 4 carers on a late shift, and 1 nurse and 1 carer on at night. In addition to these staff, “support workers” are employed to cover busy periods such as to assist with meals, enable outings etc. One trained nurse spoken with stated that for the recent review and redevelopment of care plans, Mrs Hayat had provided extra staff to ensure that sufficient time was available to accomplish this. Following a recent review of staffing levels, Mrs Hayat removed one member of care staff from nighttime staffing numbers. Mrs Hayat stated that staffing Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 20 levels are reviewed on a frequent basis, and that as occupancy and dependency levels change, so she re-evaluates the care provision required. Staff files pertaining to 4 recently recruited staff members were viewed. These files were found to be orderly, stored appropriately and held the required information, including up to date Criminal Record Bureau and PoVA checks. It was pleasing to find that significant improvements had been made with regards to these staff recruitment files. However, in most files the wrong job descriptions were present, and some references authenticity had not been ascertained. It is strongly recommended that Mrs Hayat ensure staff are provided with relevant job descriptions, a copy of which should be held on file, and that she is meticulous in checking the authenticity of received references. Records were present pertaining to staff training and courses undertaken or due to be attended included health and safety, fire safety, care planning, first aid and the Control of Substances Hazardous to Health. Records were viewed showing that overseas staff recruited to the home have been receiving training to ensure that they have appropriate communication skills. Currently 2 staff are undertaking their NVQ Level 2 in care, and 1 staff member has already attained this qualification. It is anticipated that an increase in the number of staff undertaking this qualification will be reported at the next inspection of the home. Mrs Hayat stated that training with regards to the Protection of Vulnerable Adults and the identification and Reporting of abuse has not taken place. It is a requirement of this report that such training be given priority for all care staff, but is to also include catering and housekeeping staff. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 & 38. The management of the home promotes resident focused care, and ensures residents health, personal and social needs are catered for in a pleasant, caring and homely environment. Significant improvements have been made with regards to health and safety training and monitoring within the home, thus the health, safety and welfare of residents and staff is promoted. EVIDENCE: Mrs Hayat is in the process of submitting her application to become the registered manager of Chandos Lodge, and informed the inspectors that as she is not a qualified nurse, she is looking to recruit a Clinical Nurse Manager to work with her in regards to clinical aspects of care provision within the home. Mrs Hayat handles finances for 2 residents accommodated at the home. Records pertaining to this action appear in order, with money held in a high Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 22 street bank. In the past this practice has been scrutinised by local Social Services and appeared satisfactory. Mrs Hayat stated that she is to attend training in Health and Safety. Records pertaining to hot water temperatures in bathrooms and showers were noted, and these records were up to date and well maintained. The homes fire logbook held details as to the testing of alarm systems, staff fire drills and emergency lighting tests. Staff training records relating to fire safety were seen and appeared satisfactory. Accident reporting books are maintained by the home. These records were viewed and appeared detailed and informative. Up to date certificates were seen pertaining to fire safety systems, gas safety, lift servicing, hoist servicing and portable (electrical) appliance testing. These appeared in order. Up to date certificates for insurance were viewed and appeared up to date. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 23 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 1 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 X 3 3 Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP16 Regulation 22 Requirement The home is to hold a detailed, chronological and comprehensive record of all complaints received and investigated, and of any action taken to address said complaints. All care staff must receive training with regards to the Protection of Vulnerable Adults and the identification and reporting of abuse. Timescale for action 01/05/06 2 OP18 13(6), 18(1) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP15 OP30 Good Practice Recommendations When assisting residents with their meals, staff should sit next to them to assist as opposed to standing over them. It is recommended that the chef undertake training specific to the dietary needs of elderly people and provision of special therapeutic diets. It is strongly recommended that all catering and housekeeping staff are included in training pertaining to DS0000019192.V276424.R01.S.doc Version 5.1 Page 25 Chandos Lodge Nursing Home 4 OP37 5 OP8 the Protection of Vulnerable Adults and the identification and reporting of abuse. It is strongly recommended that the consent of the resident be obtained and recorded before the care plan is shared with people other than their Next of Kin and the homes care staff. It is recommended that the settings for pressure relieving mattresses be recorded for individual residents in their care plans and/or on their beds. Chandos Lodge Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Nursing Home DS0000019192.V276424.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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