Inspection on 13/12/06 for Chapel Garth

This inspection was carried out on 13th December 2006.

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

Other inspections for this house

Chapel Garth 13/06/08

Chapel Garth 22/11/05

Chapel Garth 13/06/05

Chapel Garth 30/11/04

Chapel Garth 02/06/04

Chapel Garth 18/02/04

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

CARE HOMES FOR OLDER PEOPLE Chapel Garth Central Avenue Bentley Doncaster South Yorkshire DN5 OAR Lead Inspector Stuart Hannay Key Unannounced Inspection 09:45 13th December 2006 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 Chapel Garth DS0000007975.V303686.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. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chapel Garth Address Central Avenue Bentley Doncaster South Yorkshire DN5 OAR 01302 872147 01302 872107 NONE None Bestquest Limited 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) Elaine Mary Lindsay Care Home 33 Category(ies) of Dementia (32), Old age, not falling within any registration, with number other category (1) of places Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total registration to include one bed for the elderly Date of last inspection 22nd November 2005 Brief Description of the Service: Chapel Garth is an adapted and extended building that provides specialist residential care for up to 33 older people with dementia. The service users accommodation is entirely on the ground floor. There is an upper floor but this is used exclusively by staff. All the bedrooms are single occupancy and there are a range of communal areas which are kept accessible to service users at all times. The home is located in Bentley on the outskirts of Doncaster. It is close to local shops and amenities. There is a regular bus service into the centre of Doncaster that passes close by. The charges at the time of this inspection were £410.00 per week. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted for five and a half hours. Most of the service users were seen by the inspector and four were formally interviewed. Four relatives were also interviewed as well as the manager and two care staff. A check was made of the medication, the health and safety records, the environment and a number of records relating to care and staffing at the home. What the service does well: All the service users who were able to clearly say said that they felt well cared for and enjoyed their time at the home. The other service users, who could not clearly communicate appeared to be clean, well dressed and settled in their environment. All the relatives interviewed spoken with felt that their relatives were well cared for. The service users are fully assessed prior to them moving in to the home. The medication system was generally well managed and the service users had care plans which clearly described the care that they needed. Routines were flexible at the home and a range of activities were provided for the service users. Staff were observed treating the service users in a friendly, patient and respectful way. The service users said that they enjoyed the food. Service users’ bedrooms were clean, tidy and reasonably decorated. They had been able to personalise their rooms if they wished to do so. The rooms are kept locked for the safety of the more disorientated service users but those people who are able to look after a key to their rooms had been given one and were able to use their rooms whenever they wanted to. Service users, relatives and staff felt that there were usually sufficient numbers of staff on duty and the rotas showed that staffing levels had been consistently maintained. Checks had been made on new staff who were recruited to work at the home. Staff had undertaken statutory training and training related to the needs of the service users. The manager is suitably qualified and experienced to run the home; there was a pleasant and relaxed atmosphere on the day of the inspection. Care staff said that the senior staff were supportive. Relatives and service users said that this was usually the case. Fire training records were of a good standard and external companies had checked all the major systems in the home. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 6 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. Chapel Garth DS0000007975.V303686.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 Chapel Garth DS0000007975.V303686.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had written information about the service for potential service users and their relatives. Assessments of the service users had been made prior to them coming into the home, ensuring that the staff were able to meet their needs. The staff team had received a range of training to ensure that they understood the needs of the service users. EVIDENCE: The home had a detailed statement of purpose and service users’ guide, which described the range of services available. Three care plans checked contained assessments completed prior to the service user coming into the home. The service users and their relatives felt that their health and personal care needs were met and the care plans identified what help they needed. Two service users and two relatives interviewed confirmed that they had been able to visit the service prior to moving in. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 9 The manager was aware of the need to ensure that the needs of the existing service users are taken into account when referrals are made for new service users. The home does not provide intermediate care but does provide a respite service. Chapel Garth DS0000007975.V303686.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were plans in place to identify what help and support service users needed. They appeared well cared for and their care plans indicated that health and personal care needs are identified. Service users and relatives felt that the staff treated the service users with respect and kindness. The medication system was generally well managed but the home needs to ensure that its policy on handwritten entries on medication sheets is consistently followed. EVIDENCE: Three service users’ care plans were checked; these were detailed and identified the personal, social and healthcare needs of the service users. There was guidance for staff on what they needed to do to ensure that service users’ needs were met. The focus of the care plans was very positive, choosing to look at service users’ strengths. Specific information regarding dementia was incorporated into the plans. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 11 The plans checked had been reviewed on a monthly basis to ensure that the information and guidance was still valid. There were records of contact with opticians, dentists and chiropodists and other professionals. Four service users formally interviewed said that they could choose when to have a bath and one said that she preferred a shower and was able to have one. Two relatives spoken with said that they felt their relative was well looked after and was referred to a GP or any other professionals when necessary. The care plans contained risk assessments and these had been regularly reviewed. Four service users spoke with the inspector about the home. Most were able to clearly say how they felt about the service and all said that the staff treated them in a respectful and friendly way. Relatives spoken with confirmed that they always found there to be open and friendly atmosphere within the home. Staff and service users felt that the dignity of service users was maintained by ensuring that they were spoken to in a respectful manner and that toilet, bathroom and bedroom doors were kept closed when personal care was being provided. Staff interviewed were aware of the need to consider service users’ feelings at all times. Medication was securely stored and there were systems in place for receiving the medication into the home. There were medication administration (MAR) sheets for each service user; these recorded the type of medication, the dosage and how it was to be administered. There were reasonable stock levels in the home. Staff members who gave out medication had been assessed by external assessors as competent. Records were kept of each time the medication was given and all entries were filled in. The system had been checked by the home’s pharmacist on a regular basis. Controlled drugs were safely stored and there were two signatories for the administration of controlled drugs. When a medication had been received in between the regular deliveries, staff had to sometimes copy prescription information by hand from the medicine label onto the printed medication sheets. The deputy manager said that the policy is that any entries made by staff will be checked by a second person to ensure that the information is accurate and service users are receiving the proper medication and dosage. However, there were some handwritten entries on the medication sheets which had not been signed or witnessed. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users felt that there were suitable activities provided at the home to keep them stimulated. Visits from relatives and friends were encouraged ensuring that service users kept in touch with people who were important to them. Service users said that the food was good and they were offered plenty of choice; special dietary needs and preferences were recorded in the individual care plans. EVIDENCE: Of four service users spoken with, all said that they felt there were enough activities at the home. Relatives interviewed also felt that there was lots going on at the home and that they were also encouraged to join in. Activities included chair exercises, board games and bingo. There were entertainers who came regularly into the home and all the service users said they were ‘very good’. The manager was developing the care plans to ensure that the activities could be more specifically targeted at people with dementia. All the service users spoken with said that their relatives were welcomed into the home by the staff and were encouraged to stay for as long as they wished. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 13 Four relatives spoken with said that they were always made to feel welcome at the home and that the staff were very friendly. All said that they had been involved with decisions about the service user’s care. The inspector ate lunch with the service users. The meal was well prepared and served in a relaxing atmosphere. All the service users were eating in the lounge area as the dining room was in the process of being redecorated. Service users interviewed said that the food was of a good standard. The service users were offered a choice of meal each day and had a choice of puddings. There was information recorded in the service users’ care plans about their likes and dislikes and any special dietary needs. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 14 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, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure to allow service users to raise any concerns. The staff had been trained in the recognition and reporting of abuse and checks were made on them prior to them starting work, which reduced the risk of harm to vulnerable service users. EVIDENCE: The complaints procedures were detailed and contained all the required information. Service users said that they would not have any hesitation in raising concerns with the staff or the managers. There was a complaints book but no complaints had been made since the previous inspection. All the relatives interviewed said that they would feel happy about raising concerns with the manager or staff. There was a system in place to record and report allegations of abuse and staff interviewed had undertaken training in this area. There were training sessions for staff in recognising and reporting abuse. They were aware of their responsibilities with regard to the reporting and recording of abuse. Service users had been asked if they wished to vote in elections. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 15 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, 21, 23 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean, tidy and well maintained ensuring that the service users live in pleasant and comfortable surroundings, however the carpets in some areas needed replacing. The bedrooms were clean and fresh smelling. One bathroom was being used as a storage room for wheelchairs and the lighting in some parts of the home was poor. EVIDENCE: The communal areas of the home were light and pleasantly decorated. The carpets in the lounge and dining rooms looked marked and stained. The manager said that these had been professionally cleaned and were due to be replaced straight after Christmas. The lighting in one of the corridor’s checked was not very bright and the home needs to ensure that this is not a risk to service users. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 16 Six bedrooms were checked, two on each wing of the home. They were pleasantly decorated, personalised and clean. A range of furniture had been provided for the service users and four people interviewed said they were happy with their rooms. The bedrooms were kept locked to prevent the more disorientated service users going into peoples’ rooms and removing belongings. Two service users interviewed said that they had been provided with keys to their rooms and could go into them whenever they wished. The bathrooms and toilets checked were clean and well maintained, however, one bathroom was being used to store wheelchairs. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff deployed to ensure that the service users’ needs could be met. Staff had received statutory training and training in understanding the needs of service users with dementia. Checks had been made on staff to reduce the risks to vulnerable people. EVIDENCE: There were generally 4 care staff on duty on the morning shift, plus the senior carer. In the afternoons there were 3 care staff and a senior carer. At nights, there were 2 carers and a senior carer. This was confirmed by the staff interviewed and on the rotas checked. The manager is supernumerary to this. The service users interviewed confirmed that they felt their personal and social needs were met. The service users’ action plans and daily progress notes supported this. The recruitment records of two staff members were checked and both had 2 good references. CRB (Criminal Records Bureau) checks and POVA (Protection of Vulnerable Adults) checks had been completed on both staff members – no issues had been raised on these. There is an induction programme for new staff. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 18 There was a comprehensive programme of statutory training and training about understanding the needs of people with dementia. Staff interviewed felt that there was a strong commitment to training and that they were expected to participate in this. The home is hoping to achieve 50 of care staff with an NVQ Level II in care by early next year. They had received regular fire and manual handling training but not all care staff had up-to-date food hygiene certificates. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 19 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, 33, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff felt that their line managers were supportive and approachable and there was a well-established system of professional supervision but not all staff had had this at the required frequency. Service users were involved in making decisions about their care and had control over issues that affected their lives. Checks had been made on the major systems in the home, such as fire and gas installations, to ensure that the home was safe for service users. Fire training had been provided for staff to reduce the risk to service users in an emergency. Some repairs to the fire alarm system had not been addressed quickly enough. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has significant experience in working with older people and has achieved NVQ Level 4 in Management and Care. Staff interviewed said that the senior staff are supportive and give clear guidance about what is expected of them. They said that they would have no hesitation in raising concerns with her about the service users or other issues at the home. Relatives and service users spoken with felt that they were consulted about how the home was run. All staff received regular, professional supervision from their line managers and there are regular audits made of the service by the owners. The manager said that the staff had not received supervision at the frequency identified in the standards. There were certificates in place to show that registered contractors had checked the passenger lift and the fire, gas and electrical systems. There were no major hazards noted during the check of the building. Staff had received regular fire training and those interviewed could clearly describe the procedures to be followed. There was a gap in the records of the testing of the alarm due to there being a problem with resetting the system; the fault had been reported quickly but the contractor had not been out to make the repair. This was addressed by the manager on the day of the inspection. During the inspection a service user was noted being pushed around the home in a wheelchair without footplates on it. This chair was being pushed by a relative. The manager confirmed that these should have been in place. Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 21 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 Standard No Score 16 3 17 3 18 3 2 X 2 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 2 Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13 Requirement Handwritten entries on the medication sheets must be signed by the person making the entry. A second person must also check and sign to confirm that the information is accurate. The lounge and dining room carpets must be replaced. The home must risk assess the lighting in the corridors on each wing of the home to ensure it is safe and adequate for the needs of the service users. The home should find suitable storage areas other than bathrooms for wheelchairs. Care staff must have updated food hygiene training. 50 of care staff must be qualified to National Vocational Qualification level 2 The frequency of supervision sessions should be increased to six times per year for each staff member. DS0000007975.V303686.R01.S.doc Timescale for action 30/01/07 2. 3. OP19 OP19 23 13 10/02/07 25/02/07 4. 5. 6. OP21 OP30 OP30 13 18 12 25/03/07 30/03/07 30/03/07 7. OP36 18 & 19 30/03/07 Chapel Garth Version 5.2 Page 23 8. OP38 13 Repairs must be carried out quickly to faults in the fire alarm system. Foot plates must be used when a service user is in a wheelchair. 30/01/07 9. OP38 13 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chapel Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield SP 2LR 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 Garth DS0000007975.V303686.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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