Inspection on 22/11/05 for Chapel Garth

This inspection was carried out on 22nd November 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 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 Alan Bartrop Unannounced Inspection 22nd November 2005 10:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 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.V264836.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chapel Garth Address Central Avenue Bentley Doncaster South Yorkshire DN5 OAR 01302 872147 01302 872107 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) Bestquest Limited 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.V264836.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total registration to include one bed for the elderly Date of last inspection 13th June 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. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place between 11:00 and 15:30. The inspection involved talking to service users, relatives, staff, and the manager. A tour of the building, and the sampling of a lunch. What the service does well: What has improved since the last inspection? What they could do better: When people are employed there is a need to improve the procedure for getting satisfactory references. The way residents money and valuables is recorded and stored must be improved to ensure that items do not become lost in the system. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 6 The proprietors must visit the home on a monthly basis and leave a report of what they found during their inspection available for viewing by Commission For Social Care Inspection staff. 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.V264836.R01.S.doc Version 5.0 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.V264836.R01.S.doc Version 5.0 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): 3,6 Intermediate care is not offered at Chapel Garth. All prospective service users are assessed to ensure that the home can meet their needs should they choose to come here. EVIDENCE: The home is not registered to care for people who are categorised as needing Intermediate care, there are no specific facilities, and none of the service users were admitted into the home under this category. The care plans are produced using the format introduced by the Alzheimers Society. The completion of the care plans has improved since the last inspection with the information they contain being much more relevant. There were instances noted where service users were being checked on two hourly at night when there was not need for this identified in the care that they needed. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,10 The cleanliness of the medication room is much cleaner and the record keeping has improved but there are still storage issues that need to be addressed. The care plans have improved since the last inspection and now contain more relevant information. The service users health is monitored and they have access to appropriate support from outside professionals. Any care needs they have are dealt with in a private manner and discreetly. EVIDENCE: A new floor covering has been fitted and the room was clean and tidy. There were tablets in the medication cupboard that were for returning to the chemist that were not appropriately stored. There were personal items from service users, some of whom were no longer in the home, inappropriately stored in the medication cupboard. All the service users have a care plan which identifies their care needs and the ‘Contact Sheets’, indicate that the care has been given appropriately. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 10 The health needs of the residents are identified and recorded. Where specialist needs are identified the staff seek help from outside medical professionals. The residents are predominantly addressed by their first names and there were care plans identified where the resident’s preference about their mode of address is recorded. Service users confirmed that if they need the general practitioner they are examined in their bedroom. Staff were head to offer service users personal support in a way that was discreet and did not draw attention to the fact that this was needed. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 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 the following standard(s): 13,14 There are very few restrictions on visiting and the residents can see visitors in private if they want to. There are different facilities available for the handling of service users money and bringing personal items into the home. EVIDENCE: A relative spoken to confirmed that they could visit any time but that they avoided meal times and early morning/ late evenings. Residents said that their visitors could either see them in the communal areas or in private. There are different lounges in the home where service users can receive visitors. Residents have brought personal belongings into the home especially for display in their bedrooms. Residents said how important it was for them to bring photographs of their family in and to put them up in their bedrooms. See Section 35 about the storage and recording of personal items. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 12 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): 18 There are robust procedures in place to ensure that the service users are protected from abuse. EVIDENCE: The Adult Protection Procedures in the home are those of Doncaster Metropolitan Borough Council. There have not been any issues of Adult Protection since the last inspection. The procedures are available in the office for any member of staff to use. The staff are aware of their duties should they see any of their colleagues treating a service user in an improper way. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 13 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): 19,26 There is a program of planned maintenance to ensure that any damage to the home can be repaired promptly. The home was clean and tidy, and there were no unpleasant odours. EVIDENCE: There was evidence that minor damage to the home had been recently repaired. The gardener was maintaining the areas outside the home at the time of the inspection. The date of the last Environmental Health and Fire officer visit is recorded on the reports of Regulation 26 visits to the home by the proprietor. The laundry is adequate to meet the needs of the home and the staff confirmed that all the equipment worked. An inspection of the premises revealed that it was kept clean and tidy. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 14 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): 29,30 Each prospective employee goes through a recruitment procedure but these were not found to be full proof. There are training opportunities for new starters and existing staff but the home does not have 50 of the care staff trained to National Vocational Qualification level 2. EVIDENCE: Staff files were inspected and found to contain up to date Criminal Records Bureau checks that were satisfactory. A personal reference was found in one file that did not have the name of the person giving the reference on it, nor was it signed by the person giving the reference. A reference had been received which was not satisfactory, the manager stated that she had rung the referee about what they had written but this conversation was not recorded and the manager could hardly remember what had been said during the conversation. The filing system has been improved in the office and records are morfe easily retrieved. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 15 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): 33,35 There is a policy regarding how money and valuables are held on behalf of service users but this is not always followed. The proprietors have failed to meet the requirement that they visit the home at least monthly and leave a report stating what they have found during their inspection. Risk assessments for the building are up to date. EVIDENCE: Watches, a gold coloured ‘wedding’ type ring, and purses containing money were found in the medication cupboard, these items were not easy to trace the owners from as they were not marked with a name. One purse was identified in the medication cupboard that had some money in it and it belonged to a resident who had died about a year ago. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 16 AT the last inspection the proprietors were required to visit the home on a monthly basis and leave a report of this visit. They have chosen not to carry out these duties. Risk assessments of the building were checked and found to be up to date. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X x Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 18 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 OP9 Regulation 13 Requirement Medication for returning to the pharmacist must be stored in an appropriate container which can be sealed Personal references for prospective employees must be signed and contain the name of the person giving the reference Where an unsuitable reference is sent for a prospective employee any follow up telephone conversation relating to the reference must be recorded and kept available for inspection Residents valuables must be correctly recorded and stored, 50 of care staff be qualified to National Vocational Qualification level 2 Up to date and monthly Regulation 26 reports must be available within the home Timescale for action 01/01/06 2. OP29 19 01/01/06 3. OP29 19 01/01/06 4. 5. 6. OP35 OP30 OP33 20 12 26 01/01/06 01/01/06 01/01/06 Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 19 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 OP3 Good Practice Recommendations Residents are not checked upon during the night unless there is an identified need for this in their care plan. Chapel Garth DS0000007975.V264836.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster 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. 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