CARE HOMES FOR OLDER PEOPLE
Chapel Lodge 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR Lead Inspector
Mr Jeff Pearson Unannounced Inspection 15th November 2005 09:30 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 Lodge DS0000009502.V258491.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 Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Chapel Lodge Address 11 Hall Street Worsthorne Burnley Lancashire BB10 3NR 01282 413901 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) Dr Zahid Mahmood Dabir Mrs Naila Dabir Mrs Julie Patricia Harrison Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The registered provider should, at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. The home can accommodate 22 older persons and 1 older person with dementia DE(E) making a total of 23 residents. 27th April 2005 Date of last inspection Brief Description of the Service: Chapel Lodge is registered to accommodate up to 22 older people over the age of 65 and 1 person with dementia over 65. The residents are either privately or Local Authority funded. The home is a converted chapel with some bedrooms overlooking the cemetery. Chapel Lodge is in a residential area in the village of Worsthorne about two miles from Burnley town centre. There are some local facilities nearby such as a general store, post office, public houses and a Church quite close to the home. There is a small parking area to the front of the home, also a gardens and a patio area. Garden furniture is provided. A ramp provides access to the front door. The home has inter-connecting sitting rooms and a dinning area. All the bedrooms are single, some have en-suite toilets. Staff are available to provide assistance with personal care and support. The home can provide for recreational activities. The registered providers live next door to the home. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took 8 hours and was carried over one day by one inspector. There were 23 residents accommodated. The files/records of 3 residents were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of residents. The records of the most recently recruited staff were looked at. During the inspection, the residents, visitors Manager, and staff were spoken with. A tour of the premises was carried out. Policies and procedures were looked at. Completed comment cards were received from 4 residents and 3 relatives/visitors. The Manager had completed a pre-inspection questionnaire. What the service does well:
The atmosphere at Chapel Lodge was welcoming, supportive and friendly. The home was pleasantly decorated the furnishings and fittings were of a good standard; the residents said they liked the accommodation provided, one resident said “I was quite apprehensive about moving in, but I have been made very welcome, the staff are great” The home was being well run and there were lots of good practices in place. There was a good method of finding out about peoples’ needs and wishes before they moved into the home. The residents’ were generally happy with the activities available and residents meetings were being held so people could get involved and be consulted. Daily routines were fairly relaxed so people could be flexible in how they spent their time. People were being encouraged as far as possible, to make their own decisions and choices about things which affected them. The catering arrangements were good, all the residents spoken with appreciated the food provided one said, “yes the meals are good, they ask us what we want” The programme of staff training and development was well established. The residents appreciated the staff and relationships between everyone in the home good. “The staff work extremely hard and give an excellent service,” wrote one relative/visitor. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection?
Senior care staff and the registered manager had received medication management training. A new medication system had been introduced. The use of portable radiators had stopped; this had helped provide a safer environment for the residents. Some assessments around the home had been carried out to reduce the risks to residents and staff. The residents were being supported to use their wheelchairs properly. The home was clean and did not have any unpleasant smells; new carpets had been fitted on corridors. The ground floor bathroom had been tidied up. A survey had been carried out with the residents to find out if they were happy with the services provided. More training had been arranged for staff so they can develop their skills in providing good care for the residents and to make sure they can do their jobs properly. The manager had worked hard on updating guidelines for staff so they are clear how they should do things in the home. The homeowners were supporting the manager by letting her get on with the job and providing funds to make improvements for the benefit of the residents. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The admission process ensured the residents’ were properly assessed, their needs and wishes known and planned for prior to moving into the home. EVIDENCE: The resident’s case files seen included assessment information from Social Services as appropriate and staff at the home had carried out pre admission assessments. The assessment details included relevant information. Each resident had a care plan in place. One resident spoken with explained how the Manager had been to see him prior to moving into the home. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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, 9 The residents had individual care plans, but not all needs/wishes had been noted. Staff were not being fully instructed to respond to the residents’ individual needs and abilities. Improvements had been made with medication management, but policies and practices needed further attention for the protection of the residents and staff. EVIDENCE: Residents spoken with had an awareness of their care plans, they had signed in agreement with them and had been involved with reviews. The care plans seen as part of case tracking, were lacking in specific details of actions to be taken by staff to meet identified needs. Some care needs were not properly specified. There was no clear difference between ‘assessment’ and ‘action’. All staff responsible for administering medications had received accredited training. A new medication management system had been introduced; a different pharmacist had been contracted. Medication management policies had been revised, but still needed further matters adding, including covert administration and medication leaving the home with residents. A policy and risk assessment format was in use to support residents wishing to manage
Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 11 their own medication. Medication storage was satisfactory, temperatures were being recorded. Records were mostly accurate and well kept, but clarity was needed to explain when medication was not given, and ‘when necessary’ guidelines still needed to be specific to individual residents. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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, 14, 15 Flexible lifestyles and activities were being encouraged in response to individual and group needs, abilities and wishes. Residents were being given the opportunity to make choices and decisions, to enable them to have as much control over their lives as possible, but there was further scope for promoting rights. The catering arrangements were good, offering choice and variety. Specific diets were being catered for. EVIDENCE: Residents meetings were being held every two months, the record of the last meeting showed various matters had been discussed. Residents spoken with felt their views and suggestions were listened to and acted upon. Residents and staff described the various activities available, including various games, sing-a-longs, visiting entertainers and celebrations such as Halloween and fire work parties. A volunteer visited the home to play dominoes during the afternoon. Residents said they were able to go to bed and get up, whenever they wished, and were observed to spend time in their rooms. Comment cards
Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 13 received from residents following the inspection indicated activities were only ‘sometimes’ suitable, so this will need discussing in future residents meetings. The residents had been encouraged to bring their own personal possessions and furniture with them, detailed records were seen of such items. The residents were seen being supported and enabled, to make their own choices and decisions. Financial arrangements were outlined in the homes guide, residents where possible managed their own monies. There was some information within the complaints procedure about advocates. There was no information or guidelines about residents having access to the written records kept about them. The residents spoken with said they were happy with the quality, variety and choice of meals provided. Three full meals were being offered daily. A four week menu system was in place; the cook said the menus were to be reviewed with the residents. Choice menus were available, the options being discussed with residents each day and were on display in the dining area. Diets such as diabetic and low fat were being catered for. Drinks and snacks were readily available. The record of meals served showed much detail. Promoting independence at mealtimes could be encouraged further. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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): 18 The progress made with protection and abuse training for staff, had helped to provide a safer care service for the residents. EVIDENCE: A training agency had visited the home to provide protection and abuse training for staff; records were seen of staff receiving this. Some staff had covered abuse matters as part of their induction and NVQs (National Vocational Qualifications) in care. Policies and procedures were seen to be in place for the protection of the residents, including abuse awareness, dealing with aggression and physical intervention. Abuse and protection procedures include appropriate information including the contact details for making referrals. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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, 26 The standard of the accommodation had improved; providing the residents with an attractive and homely place to live, some matters needed attention to ensure the residents have and appropriate facilities. EVIDENCE: The home was seen to be generally in good order. A new system had been introduced for identifying and following up any matters in need of attention, including refurbishments. The décor was a satisfactory standard, new carpets had been fitted on the back corridors. The ground floor bathroom had been tidied but was still in need of attention to provide a more suitable facility for the residents. The ground floor shower was unsuitable for most people living at Chapel Lodge; the manager said an issue about drainage had stopped progress in improving this facility.
Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 16 The home was clean and fresh smelling, action had been taken to deep clean some carpets and air neutralisers had been placed in bedrooms. The manager said consideration was being given to using an enzyme based cleaning product. A new clinical waste policy had been introduced. Seven staff had completed infection control training; others were to attend later in the month. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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, 30 Staffing arrangements although sufficient, needed monitoring to ensure the residents’ needs are effectively and safely met. Progress had been made in enabling staff to gain recognised qualifications to improve the quality of service for the residents. Staff recruitment practices needed to be improved for the protection of the residents. EVIDENCE: The residents spoken with were complimentary about the staff team. The required numbers of staff were on duty. Staff rotas and records of hours worked, indicated that appropriate staffing levels were being kept, with extra staff also being on duty on some days. Two staff were on waking watch duty at night. There were enough catering and cleaning staff employed at the home. Comments received from relatives suggested more staff would be better, particularly at weekends. The manager agreed to review the current arrangements. Half of the care staff had attained NVQ level 2 in personal care. Four staff were doing NVQ level 2. Two staff had completed NVQ level 3 one was doing this level.
Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 18 Staff records checked were found to have some discrepancies. Employment histories did not include enough detail and there were no records to show gaps in employment had been looked into. No interview notes were available. Applicants had been provided with job descriptions but not person specifications. All new staff were being supported to undertake recognised induction training and the homes own induction programme. Records seen indicated the staff training completed and planned for. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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, 35, 38 The manager of Chapel Lodge had the ability, experience and qualifications to effectively manage the service for the benefit of the residents. Some progress had been made in introducing quality systems to help ensure the home is run in the best interest of the residents. Appropriate systems were in place to manage residents’ monies, charges and payments. Arrangements had been made to maintain health and safety; some further safeguards were needed to promote the well being of residents and staff. EVIDENCE: Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 20 The atmosphere in the home was found to be relaxed and welcoming. The residents staff and manager seemed to get on well together. Julie Harrison, registered manager had attained NVQ level 4 in management and care and had recently completed the Registered Managers Award. She had also attended other relevant training courses. Lines of accountability within the management structure were clear. Staff meetings were being held on a regular basis, and the registered providers were accessible and supportive to the manager. Residents spoken with were happy with management of the home; staff said the manager was approachable and helpful. It was good to hear Internet access was being considered, this would enable access to up to date information and provide further opportunity for the residents to keep in touch with relatives. An anonymous questionnaire/survey had recently been given to the residents; the results were being looked at. Relatives, staff and others such as GP’s, Community Nurses and Social Workers were yet to be consulted. The homes’ guide included information about financial matters. Records seen indicated accountable systems were in place to manage residents’ pensions, monies and charges and payments. Secure storage was available. The home was found to be free from any obvious hazards to health and safety. Documents were available showing the servicing of equipment and installations. The residents’ wheelchairs were fitted with footrests. Records were seen of various checks including water temperature and fire equipment. All senior staff had completed First Aid training. Training in safe working practices was ongoing, or being arranged. Health and Safety risk assessments had been completed on residents’ bedrooms, these needed to be carried out on all other areas in and out of the home. Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement Care plans must include all identified needs and be in sufficient detail to provide clear guidance to staff, of the actions to be taken, to meet the residents health and welfare needs. Instructions following specific assessments and risk assessments must be included in care plans. When residents are not given their prescribed medication, the reasons for this must be clearly recorded. Bathing facilities must appropriately meet the needs of the residents (Timescale of 01/08/05 not met) The recruitment of staff must include the obtaining and checking of full employment histories, with records kept. Timescale for action 17/02/06 2 OP9 13 18/11/05 3 OP21 23 31/03/06 4 OP29 17,19 18/11/05 Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 23 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 OP7 OP9 Good Practice Recommendations The care planning system should ensure all the residents’ needs and wishes are fully recorded and the specific action to be taken by staff, clearly noted. Individual protocols should be written to provide clear agreed instructions for staff, on when to give ’when required’ medication (Outstanding from last inspection) The ‘key’ used on medication records should include ‘not given medication’ Medication management policies and procedures should include, when required medication, covert administration, medication going out of/returning to the home. The residents should be provided with written information about external agents who may act in their interests, for example advocates, this could be included within the homes’ guide. Policies and procedure should be written and introduced in line with the Data Protection Act, to support the residents in having access to the written information kept about them. A summary of this could be included in the homes’ guide. The application form for staff should be revised to ensure all appropriate information is obtained from applicants. Records of responses in employment interviews should be kept. Person specifications should be produced for the various positions at the home. The quality assurance system should involve contacting all people having an interest in the services provided at the home and should result in a development action plan being produced. Health and safety risk assessments should be carried out on all areas of the home, outside pathways and grounds. Training in safe working practices needs to continue. 3 OP14 4 OP29 5 OP33 6 OP38 Chapel Lodge DS0000009502.V258491.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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