CARE HOMES FOR OLDER PEOPLE
Chapel Lodge 11 Hall Street Worsthorne Burnley BB10 3NR Lead Inspector
Jeff Pearson Unannounced 27 April 2005 9.30 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 Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Chapel Lodge Address 11 Hall Street Worsthorne Burnley Lancs BB10 3NR 01282 413901 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) Dr Zahid Mahmood Dabir Mrs Julie Patricia Harrison Care Home 23 OP DE(E) 22 1 male Category(ies) of Old Age registration, with number Dementia of places Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered provider should at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection 2. The home can accommodate 22 older persons and 1 older person with dementia DE(E) making a total of 23 residents Date of last inspection 18 November 2004 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. Residents are either privately or Local Authority funded. The home is a converted chapel with some bedrooms overlooking a cemetery. Chapel Lodge is situated within a residential area in a village setting. There are some local facilities such as a post office, general store, public houses and a church quite close to the home. Most community resources are situated within Burnley town centre, which is approximately two miles away. There is a small car parking area to the front of the home, also gardens and a patio area. Garden furniture is provided. A ramp provides access to the front door of the home. The home has inter-connecting sitting rooms and a dining area. All bedrooms are single some have en-suite toilets. Staff are available, to provide assistance with personal care and support, in response to individual needs/wishes. The home can provide for ‘in house’ recreational activities. The registered providers live adjacent to the home. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7½ hours. There were 17 residents accommodated. During the inspection 10 residents, 3 care assistants, the deputy manager and registered manager were spoken with. The files of 3 residents were examined along with the records of the most recently employed staff member. Documents, including policies, procedures and records were looked at. A tour of the premises was carried out. Comment cards were completed by 3 residents. What the service does well: The written information about the home provided clear details about the services and facilities available. Before new residents moved into the home, the manager went to meet them to make sure their needs could be met. Good individual plans had been written, to ensure staff knew what they needed to do for each resident. People were being enabled to live as they wished, residents said “we can get up and go to bed anytime we choose” The residents were treated with dignity and respect. Relatives were able to visit at any time and privacy could be arranged One relative said “I visit my mum every day and am always made welcome” The resident said they were happy with the food and the meal choices available. People were being encouraged to voice their opinions with meetings being held, so residents could be consulted and make suggestions. One resident said, “I would not hesitate if I needed to make a complaint, but I don’t have any” The home was ‘homely’ and pleasantly decorated; residents said they liked the accommodation provided, including the privacy of their own bedrooms. The atmosphere was relaxed and friendly, the home was being well managed. The residents spoke positively about the staff describing them as “very kind and helpful” Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better:
All staff responsible for dealing with medication needed relevant training, and needed to follow the appropriate medication procedures and recording systems. Clear guidelines were needed about when to give residents ‘when required’ medication. Residents said they would prefer to use a bathroom closer to their bedrooms. The bathing facilities must be improved to ensure the residents mobility needs are sufficiently responded to, their dignity appropriately maintained and their scope for choice improved. The use of portable radiators needed to be assessed for any risk to residents and staff, and any necessary action taken to provide a safe environment. Assessments around the home needed to be carried out, to ensure risk areas are kept to a minimum or removed. Action needed to be taken to ensure staff support the residents to use their wheelchairs correctly. Attention needed to be given to making sure all areas of the home were clean and free from offensive odours, in order to provide a pleasant and hygienic environment for the residents. A method of formally consulting with residents, relatives and others needed to be introduced, to ensure the home is run in the best interest of the residents. All the required records needed to be properly kept. Staff training and development needed to continue, including NVQ (National Vocational Qualifications) in care, basic courses such as First Aid, Moving and Handling and Food Hygiene and ‘in house training’ on the homes polices and procedures.
Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 7 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 F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 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 standard(s) 1,3. Progress had been made with providing up to date written information about the home giving prospective residents a clearer indication of services available. Action had been taken to ensure current residents were also aware what services were on offer. Full assessments were being carried out prior to residents moving into the home, this identified that their needs could be met and how. EVIDENCE: The statement of purpose and service user guide, provided further details about how the home is run and the services and facilities available. These documents were available and some residents said they had been given copies of the service user guide. The resident’s records that were looked at included assessment details, which provided a clear indication of their needs abilities and wishes. The manager left the home to assess an emergency admission during the inspection. A letter, advising prospective residents that their needs could be met at the home was available. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Care plans and care planning systems, had been developed to provide a more effective service. The resident’s health care needs had been identified and were being addressed. Some improvements were needed with medication management and recording, to ensure the residents appropriately receive their medication. The residents needs and rights to privacy and respect were being maintained. EVIDENCE: Individual care plans were available; those examined included details of resident’s needs and actions to be taken by staff in response. Family involvement had been included. Reviews were being carried out. Residents, where able, had signed in agreement with their care plans. Staff spoken with had an awareness of the content of care plans. Health related policies were available and records indicated residents were receiving attention from health care professionals. Moving and handling risk assessments had been carried out and recorded. The resident’s daily records included more detailed information. Most medication management records were clear and accurate, some were not One resident was not given medicine at lunchtime. Not all staff responsible for
Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 11 medication had received appropriate training; a letter was seen indicating such training was being arranged. These matters required attention. A policy had been written on ‘when necessary’ medication, but guidelines were needed in response to individual circumstances. Residents said they were treated with dignity and respect, this approach and maintaining privacy was observed within care practices. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 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 standard(s) 12,13,15, Visiting times were flexible so residents could keep in touch with relatives and friends. The residents were involved with practices in the home, which enabled them to influence their lifestyles, make decisions and choices. The catering arrangements were generally good and provided opportunities for choice, there was scope for encouraging further choice, independence and a more balanced diet. EVIDENCE: One relative said the visiting times were flexible and privacy could be arranged, another regularly had meals at the home. Residents spoke of the various activities available, including dominoes, movement to music and visiting entertainers. Individual hobbies, such as reading and knitting were being encouraged. Records of residents meetings indicated they had been consulted, and enabled to make suggestions, a trip to Blackpool was being considered. Residents said they were able to go to bed and get up, whenever they wished. Choices were offered at mealtimes. Residents said they were happy with the variety and quality of the meals provided. Hot and cold drinks were offered throughout the day. The dining room provided a pleasant eating environment. Meals were served ‘plated up’ staff poured out the tea/coffee for the residents. Three of the meal options offered included pastry, which was not a balanced diet and may have limited residents’ choice. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There was a clear complaints procedure indicating how residents and others should raise any concerns. The lack of training about abuse/protection procedures may prevent a proper response to any suspicion or allegation of abuse and might place residents at risk. EVIDENCE: The complaints procedure included clear and relevant information for residents and others. A copy of the procedure had been placed in each bedroom. Residents spoken with had an awareness of the procedure. One resident said if they were not happy with anything they would speak to the manager. A system was in place for people to make comments or suggestions. Policies and procedures were available, which intended to ensue the residents were protected from abuse; appropriate referral details had been included. Some staff had received formal training on abuse and protection matters. There had not been any training given to staff, about the homes abuse and protection policies and ‘localised’ referral procedures. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,24,26, Improvements had been made in the home but some matters needed attention to provide the residents with more comfortable, clean, safe surroundings and with facilities, which adequately meet their needs. EVIDENCE: A handrail had been fitted to the front ramped access. A fly screen had been fitted to the kitchen window. A record of planned refurbishment and renewal was being kept. The décor was generally of a good standard. Residents spoken with were happy with their bedrooms, keys to bedroom doors had been offered. The home was mostly clean, the carpet on one corridor was stained, two bedrooms smelt unpleasant. An ‘oil filled’ portable radiator needed guarding and risk assessing. The ground floor shower had been reconnected. The ground floor bathroom had items stored in it such as a vacuum cleaner and staff possessions. Both ground floor bathing facilities presented as insufficient in providing for the needs of the residents. The shower was not easily accessible for people with poor mobility and the space to manoeuvre the bath hoist/chair was limited. Liquid soap and paper towels had been provided. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 15 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) 27,28,29 Progress had been made in ensuring recruitment practices offer protection to people living in the home. Staffing arrangements were not satisfactory in providing for effective catering and management of the home. Training to ensure staff are competent to do their work was ongoing. EVIDENCE: Residents spoken with, made positive comments about the staff team. On the day of the inspection, staffing levels were diminished due to the absence the cook however; arrangements were made to provide additional cover in the home. Records indicated the specified staffing levels were being maintained, this was reaffirmed by residents and staff. A staff code of conduct had been defined and introduced. The records of the most recently appointed staff member, indicated the necessary recruitment checks had been carried out. Records were seen of staff induction training. Four staff members had attained NVQ (National Vocational Qualification) level 2 in care; four were due to start this training in September 2005. Not all staff had completed core training such as basic food hygiene and manual handling, but this was being arranged. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36,37,38 The Management practices and leadership approach, had improved the care and service for the residents. Some arrangements had been made to maintain health and safety; further safeguards were needed to promote the well being of residents and staff. The residents and others were not being formally consulted about the quality of the service, so had limited opportunity to influence change. EVIDENCE: The manager had been successful in her application for registration with the Commission and was awaiting the results of her NVQ level 4 training. A manager job description had been defined. The manager considered she had sufficient time and support to undertake her duties. Several policies and procedures were seen to have been updated. Most records were appropriately kept, some needed attention. Staff said meetings were being held regularly. A ‘carer of the week’ incentive scheme had been introduced. Residents spoken with expressed confidence in the homes management arrangements. The
Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 17 home had attained ‘Investors In people’ accreditation. Records were seen of staff supervision sessions. There were no formal quality assurance/consultation systems being carried out. Documents were available showing the servicing of equipment and installations. Residents were not being assisted to use footrests on their wheelchairs. Staff had received ‘in house’ fire safety training. Not all staff had received health and safety training, but this had had been arranged. Risk assessments had not been completed for all safe working practices in the home. Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x 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 x 15 2
COMPLAINTS AND PROTECTION 3 x 2 x x 3 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x x 3 2 2 Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 19 yes 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 9 Regulation 13 Requirement All staff authorised to administer medication must receive accredited medicines management training. Service users must be given their medication at the prescribed time. All medication must be signed for at the time of administration.l Bathing facilities must appropriately meet the needs of the service users. The potential risk of the portable radiator, must be assessed and any action taken as necessary The home must be kept clean and free from offensive odours. A formal system for reviewing and improving, the quality of care provided at the home must be implemented. (Timescale of 21/1/05 not met) The required records must be appropriately kept (Timescale of 3/12/04 not fully met) Risk assessments for safe working practices must be carried out. The residents must be supported to use their wheelchairs appropriately.. Timescale for action 8/7/05 2. 3. 4. 5. 6. 7. 9 9 21 25 26 33 13 13 23 13,23 13,16 24 27/4/05 27/4/05 1/8/05 6/5/05 31/5/05 1/6/05 8. 9. 10. 37 38 38 17 13 13,23, 31/5/05 31/5/05 27/4/05 Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 20 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 9 Good Practice Recommendations Individual protocols should be written to provide clear agreed instructions for staff, on when to administer when required medication. (Not fully addressed from last inspection). The residents should be provided with further opportunities for retaining/developing independence skills at meal times. Further consideration should be given to providing a balanced diet when devising menus. Staff need to be made aware of the localised procedures for refering abuse/allegations of abuse.l The carpet in the back corridor should be deep cleaned or replaced. Every effort should be made to provide appropriate cover for all staff abscences. Staff should continue to be supported and enabled to undertake appropriate NVQ training. 2. 15 3. 4. 5. 6. 18 26 27 28 Chapel Lodge F57 F07 S9502 Chapel Lodge V223790 270405 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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