Inspection on 13/06/05 for Chapel Garth

This inspection was carried out on 13th June 2005.

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

Chapel Garth 13/06/08

Chapel Garth 13/12/06

Chapel Garth 22/11/05

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 DN5 0AR Lead Inspector Alan Bartrop Unannounced 13 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 GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chapel Garth Address Central Avenue Bentley Doncaster South Yorkshire DN5 0AR 01302 872147 01302 872107 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) Bestquest Limited Mrs Elaine Lindsay PC Care Home only 33 Category(ies) of De Dementia 32 registration, with number OP Old Age 1 of places CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Total Registration to include 1 bed for the elderly. Date of last inspection 30 November 2004 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 user’s 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. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Chapel Garth that started at 09:30 and ended at 15:20. The inspection involved discussions with service users, relatives and staff along with an inspection of records and the building. What the service does well: 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 CS0000007975.V176716.R01.doc Version 1.30 Page 6 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 GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 7 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) 6 Intermediate care is not provided at chapel Garth. EVIDENCE: The home is not registered to provide this service. None of the service users were admitted under the scheme. The home does not have the provision needed for Intermediate Care. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 8 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) 7,9 The keeping of the care plans and records of care delivered on a daily basis causes great concern. Both in the quality of the records made and the way they are stored. The medication room was very dirty and disorganised. Some medication records were inaccurate. EVIDENCE: There were several boxes of service user details found in the upstairs toilet that were not in order, and some of these records related to current service users. Care records relating to aggression by service users did not give enough details to be useful in anticipating or preventing future incidents. The medication room and medication trolley were dirty and there were several suspension bottles that had the liquid dried on the outside where it had be poured. Temazepam was incorrectly recorded and liquid paper was seen to correct records. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 9 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) 12,15 There is a range of leisure activities provided and the service users were able to confirm that they were kept informed about what was happening. The home offers a varied diet and the menus take into account the desires of the residents. EVIDENCE: The planned activities were posted on the notice board and recorded in an activities file. Service users confirmed that they were asked if they wanted to join in with activities. On the day of the inspection the activities organiser visited the home with a dog and the residents were seen to be enjoying stroking and playing with it. The residents said how much they enjoyed the food served. A lunch was observed and the cook came round all the residents and asked for their views on the meal. Relatives commented on how much their parent enjoyed the meals and that they were happy with the persons weight maintenance. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 10 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 There is a complaints procedure which is available to residents and relatives. EVIDENCE: There have been no complaints since the last inspection, the complaints file confirmed this. Residents were able to say how they would make a complaint if they felt the need and what they would expect to be done about it. Relatives confirmed that they knew there was a complaints procedure and where they could see it if they needed. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 11 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) 26 Generally the home was reasonable clean but there were areas of the home that needed to be kept cleaner. EVIDENCE: The dining room carpet was very dirty and stained, and was in need of cleaning or replacing. Some of the toilet/bathroom areas needed a thorough clean especially in the corners. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 12 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 There was an adequate number of staff on duty to meet the needs of the service users at the time of the inspection. EVIDENCE: Staff rotas indicated that there were adequate staff allocated to each shift to meet the needs of the residents. All the staff were above the minimum age required by the National Minimum Standards. Staff were dealing with the residents in a caring and discreet manner so that those needing extra support were helped in a way that did not draw attention to them. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 13 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) 33,35 The monitoring of the home on behalf of the proprietors needs to be improved. The residents money is kept safely and the records of this are kept accurately. EVIDENCE: The monitoring on behalf of the proprietors requires that a report of their inspection and their findings is left in the home. These were not available for the months after March 2005. The records of residents money held by the staff were examined and found to be accurate when compared to the actual money held in the individual wallets. CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 14 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 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 2 x 3 x x x CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 15 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 7 Regulation 12 Requirement The care plans and daily records that are currently in boxes in the upstairs toilet be sorted and appropriately stored Care plans are reviewed as required by the National Minimum Standards Medication Room be cleaned out Timescale for action 1st August 2005 1st August 2005 2. 3. 4. 5. 6. 7. 7 9 9 9 9 33 15 13 13 13 13 26 1st August 2005 Medication Trolley be cleaned out 1st Auguat 2005 Liquid Paper must not be used to 1st August alter the medication records 2005 The Controlled Drugs Register 1st August must be correctly completed 2005 Up to date Reguation 26 reports 1st must be available within the September home 2005 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. Refer to Standard 26 Good Practice Recommendations The dining room carpet be thoroughly cleaned or replaced CHAPEL GARTH CS0000007975.V176716.R01.doc Version 1.30 Page 16 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ 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 CS0000007975.V176716.R01.doc Version 1.30 Page 17 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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