Inspection on 16/06/05 for Chapel Brook House Nursing & Residential Care Home

This inspection was carried out on 16th June 2005.

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

The inspector 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

Chapel Brook House Nursing &... 17/04/07

Chapel Brook House Nursing &... 16/11/05

Chapel Brook House Nursing &... 08/12/04

Chapel Brook House Nursing &... 27/07/04

Chapel Brook House Nursing &... 30/03/04

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

CARE HOMES FOR OLDER PEOPLE CHAPEL BROOK HOUSE Moody Street Congleton Cheshire CW12 4AN Lead Inspector June Shimmin Announced 16 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chapel Brook House Nursing Home Address Moody Street Congleton Cheshire CW12 4AN 01260-277364 01260-277364 info@chapelbrookhouse.com Stylepeople Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Louise Oldham (proposed) Care Home 32 Category(ies) of OP - Old Age (32) registration, with number PD - Physical Disability (2) of places CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 32 service users to include:* * 2 Up to 32 service users in the category of OP (old age not falling within any other category) 2 named service users in the category of PD (physical disability under 65 years) may be accommodated within the maximum of 32 beds The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Date of last inspection 8th December, 2004 Brief Description of the Service: Chapel Brook House Nursing and Residential Care Home is a Grade II listed building of Georgian style situated in its own grounds and wooded areas. It is just a few minutes walk from the town centre of Congleton and close to local amenities such as the library, shops, bus station, theatre, churches and railway station. Accommodation is provided on three floors with access between floors being provided by a passenger lift or staircases. Communal areas include a large lounge and conservatory on the ground floor. Part of the conservatory is used as a dining area. The home provides 22 single bedrooms 5 of which have en suite facilities. There are also 5 double rooms 3 of which have en suite facilities. Bedrooms without en suite facilities have a wash hand basin. A nurse call system is supplied in all bedrooms. The home provides a number of aids and adaptations for residents who need assistance. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours. 12 residents, several relatives, the homeowner, manager and 7 staff members were spoken with. Written comments were received from two health/social care professionals and 12 relatives. A tour of the home was undertaken. Care records for three residents were looked at, as well as records on fire safety, recruitment, accidents and training. What the service does well: What has improved since the last inspection? The owner has appointed a new manager and deputy manager. residents and staff were complimentary about them both. Relatives, The standard of care planning has improved. The care plan describes the actions that the home will take to meet the needs of individual residents. A new cook has also been appointed and standards of catering have improved. Food is served at an appropriate temperature. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 6 A permanent staff member has been appointed as activities coordinator, initially for 6 hours per week, rising to18 hours a week. All staff take part in a fire training session once a year and a fire drill twice yearly. 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. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 Residents and their relatives are given information about the home. The manager assesses residents before moving in; residents are not accepted if their needs cannot be met. EVIDENCE: Information about the home is displayed in the reception area. The owner also makes sure that the latest inspection report is available for residents and their families to read. Nine out of ten relatives were aware of the inspection and said that they had access to the inspection reports. The care home has its own website (www.chapelbrookhouse.com). Before residents move in, new residents are visited either in their own home or other setting, to make sure that that their care needs can be met. The manager talks to the person and writes notes about their care needs. The resident`s care needs are reassessed when they move into the home. A full written assessment was seen for a resident who had recently moved into the home. Written assessments may also be provided by a nurse or social worker. The care home does not provide intermediate care. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Some progress has been made with care plans but further improvements are needed to make sure that all residents’ care needs are met effectively. The system for managing the residents’ medications is safe but some minor improvements are needed. Residents’ rights to privacy and dignity are upheld. EVIDENCE: All residents have a care plan. Three care plans were read. The first care plan was well written and in keeping with good practice, included a care plan for potential social isolation. The plan had been recently re- written and indicated regular contact with various health care professionals. Appropriate risk assessments were provided. No care plans were in place for the prevention of pressure sores, continence promotion and communication, where these needs had been identified. A form for details of the resident`s life history had been provided, but not completed. The second care plan was also well written and showed that referrals were made to a chiropodist and optician. A plan for social isolation showed that Chapel Brook House had clearly attempted to meet this need. The care plan was written two weeks following the resident moving into the home and had been reviewed monthly. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 10 A care plan for the management of diabetes was absent, although the resident`s blood sugar levels were being monitored. There was also no care plan for the management of the resident`s disorientation and confusion and no record of the resident`s life history. The third care plan was written three days after the resident moved into the home and included appropriate risk assessments. The care plan had been kept under review. A care plan for the management of personal hygiene and particularly oral hygiene was needed. A life history had been provided by a relative. Staff spoken to, were knowledgeable about the care needs of residents. Staff act to prevent vulnerable residents from developing pressure ulcers. Specialist mattresses are supplied by the home and risk assessments identify those most at risk. The pre- inspection questionnaire (PIQ) indicated that two residents had pressure ulcers. Medication was generally well managed. Medication administration records were fully completed, although on one day there were a few gaps where a nurse had not signed the record. The carpet in the medication room was sticky. Although there were handwashing facilities there were no paper towels. Residents said that staff members treated them with respect. They said that staff knocked on their door before entering and that their privacy was respected. One resident commented “the care staff look after us well.” CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Standards of catering are good. Individual and group social activities are provided and where possible residents can express choice about their daily lives. Visitors are welcomed at the home. EVIDENCE: The activities co-ordinator at Chapel Brook House offers a variety of social activities on a one to one or group basis. The PIQ indicates that the coordinator`s weekly hours will increase from six to eighteen from July 2005. Residents who may be at risk of social isolation are identified, and steps taken to ensure that they can follow individual activities. Activities include concerts, a film club, aromatherapy, quizzes, talks and demonstrations. Recent talks were given on art, quilting, natural history, local history and music. Activities in the wider community include include days out, theatre and church visits. The home held a recent VE day celebration and photographs of the festivities were displayed in the hall. A religious service is held at the home at least monthly. Residents can express choice in their daily lives in many ways and can join in the activities if they wish. Several residents prefer to stay in their own rooms or to eat there. Many residents receive a daily newspaper. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 12 Visitors are made to feel welcome and are encouraged to take residents out where possible. Four or five families go out for Sunday lunch each week. Written comments from relatives were mainly complimentary. All said that they were welcomed at the home and could visit their relative in private. They also said that they were kept informed of important matters affecting their relative. All were satisfied with the overall care provided. The standards of catering at the home are good. A new cook has started since the last inspection. Residents said “we have a good cook and we have some lovely food” and “they feed me well.” The daily menu is displayed and showed a choice, balanced variety and special diets catered for. Drinks and snacks are always given when wanted. The main meal of the day is served at lunch. A visitor said that the cook asks individuals what they would like to eat at lunch. Care assistants were also seen asking residents. The kitchen is about to be refurbished. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Chapel Brook House has a satisfactory complaints procedure. Residents and relatives are aware of the procedure and know who to speak to if they have concerns. The home provides information about protecting residents from abuse and staff are aware of the abuse procedure. EVIDENCE: Chapel Brook House has a complaints procedure within the information folder (service user guide) clearly displayed both in the hallway, and on a wall in the hall. All relatives, except one, were aware of the complaints procedure. The PIQ indicated that no complaints were received since the last inspection. The home`s policy for the protection of vulnerable adults and whistleblowing is displayed in the staff room. The homeowner will be attending a course on this subject in the near future. Adult protection is covered during the induction process and as part of NVQ training. During discussion, staff showed they were aware of the issues surrounding adult protection and the actions to be taken if abuse was suspected. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24 and 26 The owner has an ongoing programme of redecoration and refurbishment. Overall, Chapel Brook House maintains high standards of cleanliness. EVIDENCE: The standard of the décor and furnishings is generally good. A number of areas have been refurbished/redecorated over the past year providing a more homely environment for residents. The PIQ indicates the following improvements and redecoration have taken place: refurbishment of the first floor bathroom, redecoration of nine bedrooms and some communal areas. The owner has purchased 12 new lounge chairs, 10 new dining chairs, 12 new commodes and a specialist bath. The sluice has been refurbished and a new nurse call bell system installed. Various aids and adaptations at the home assist residents with varying degrees of disability. The owner has recently introduced a “Wonderguard” system which alerts staff when a resident is moving about. This is particularly helpful at night and should reduce the number of residents who fall. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 15 No odours were detected. Written comments from relatives were seen regarding the good standards of cleanliness at the home. Residents spoken with are happy with their bedrooms. People can personalise their rooms and bring small items with them. One visitor commented about the environmental improvements and this was also written by two relatives. The pleasant gardens and seating areas are accessible to residents, with parasols and gazebos to provide shade. Residents are encouraged to help with the flowers and tubs. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Staffing levels are good with thorough recruitment procedures followed. Staff are well regarded by residents and relatives. Staff are supported to undertake training relevant to their role. EVIDENCE: The PIQ indicated an increase in staffing. Two Registered Nurses and six care assistants are on duty between 8am and 2pm. The rotas indicate however, that two Registered Nurses are on duty between 8am and 2pm between one and four days a week with very little use of agency staff. An activities coordinator leads the residents` activities. Written comments from relatives included: “the owners and staff are kind and helpful,” “very impressed with the overall care,” “staff are all very helpful and caring” and “Chapel Brook House delivers a quality service to everyone in their care.” One relative commented that “staff do not have time to chat to residents.” Ten out of 12 relatives felt that staffing levels at the home were adequate. Visitors spoken with, said that staff communicate with residents in a caring and sensitive manner. A number of staff have worked at the home for many years, which provides continuity of care for residents. Staff said that the home provided a happy working environment. Records for recruitment were complete,showing a thorough approach to recruitment. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 17 Staff are supported to undertake training. The PIQ indicated that staff have mandatory training in fire safety and moving and handling. Care assistants are working towards NVQ qualifications. Future training courses have also been scheduled. From the questionnaire, a new staff appraisal system has been introduced. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 38 Chapel Brook House is well managed by both the owner and the manager. Management act to ensure the safety and wellbeing of residents. EVIDENCE: The homeowner is greatly involved in the day to day running and is clearly committed to improving and maintaining high standards. The new manager has worked part time at the home for nine years. The manager currently works ten hours a week and intends to work full time in the near future. A full time deputy manager has also been appointed. The manager has started the process to become the Registered Manager and intends to start NVQ level 4 in management in September 2005. Staff described management as approachable and said that working conditions at the home had improved. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 19 Training records indicated that staff have undertaken fire training and participated in a fire drill within the last four months. The fire officer visited the home in February 2005 and identified issues have been addressed. The owner has provided a fire risk assessment for the home. The PIQ confirmed that the owner ensures equipment and installations are regularly serviced. Prompt action is taken to repair or replace any faulty equipment. The handyman is responsible for maintenance such as checking fire equipment, water temperatures and health and safety issues. Through reading accident records, staff take appropriate action to reduce further accidents. The CSCI is notified of events that they are legally required to be informed of. The home does not hold any money for residents; all financial affairs are dealt with by family representatives. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 x 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x x x 3 x x 3 CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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 7 9 Good Practice Recommendations Care plans should be provided for all identified needs. Care plans should be written within five working days of admission to the care home. The carpet in the medication room should be deep cleaned or replaced. Paper towels should be available in the medication room. CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 CHAPEL BROOK HOUSE F51 F01 S58768 Chapel Brook House V223912 160605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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