Inspection on 10/03/09 for Chapel Lodge Nursing Home

This inspection was carried out on 10th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chapel Lodge Nursing Home 17/03/05

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Chapel Lodge Nursing Home 105 Station Road Chapeltown Sheffield South Yorkshire S35 2XF     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Stephanie Kenning     Date: 1 0 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Chapel Lodge Nursing Home 105 Station Road Chapeltown Sheffield South Yorkshire S35 2XF 01142578727 01142578728 chapel@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Southern Cross Healthcare (Focus) Limited Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 63 Number of places (if applicable): Under 65 Over 65 63 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who may be accommodated is 63. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admisison to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places 63. Date of last inspection Brief description of the care home Chapel Lodge is a modern purpose built home that can accommodate up to 63 people. It is situated just off Station Road in Chapeltown, near Sheffield, accessed by a wide driveway shared with other properties, and is difficult to see from the main road. There is plenty of car- parking at the front of the building and there are gardens to the rear adjacent to the river. Care Homes for Older People Page 4 of 26 Brief description of the care home The building has two floors accessed by a shaft lift and several staircases. All the bedrooms are single, but of a good size with an en-suite toilet and wash- basin. Communal areas are situated in different parts of the building so that there is usually one nearby. There are ten bathrooms around the building and some toilets near to the communal areas. Although the building has operated as a home for about ten years, it was purchased by Southern Cross Health Care in 2007, requiring a new registration with CSCI. The home was then closed for six months, June to December 2007, due to refurbishment following flooding of the adjacent river. The fees range from #329 to #939, depending on a needs assessment, and do not include chiropody, hairdressing, newspapers, dental, optical, toiletries and outings. This information was provided on the 10th March 2009. The registered person makes information about the service available via the Statement of Purpose and the Service User Guide. A copy of the inspection report will be made available at the home. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection carried out by Stephanie Kenning, Regulation Inspector. The site visit took place between the hours of 9:30 am and 17:00pm. The last inspection on this service was completed on 17/03/08. The new Manager Jane Bennett was present throughout the visit and the Operations Manager Angela Jepson was present for feedback at the end of the day. Prior to the visit the Annual Quality Assurance Assessment (AQAA) had been submitted, which detailed what the home was doing well, and any plans for improvements over the next twelve months. The new manager had only been in post for about two weeks and had completed her own action plan with action points and planned dates in order to improve areas across the service. Information from the AQAA Care Homes for Older People Page 6 of 26 and the managers action plan is included in the main body of the report. A number of surveys were returned to CSCI from people using the service, working at the home, and from health professionals involved with the home. Comments and feedback from these have been included in the report. On the day of the visit opportunity was taken to make a tour of the premises, inspect a sample of care records, check records relating to the running of the home and check some of the policies and procedures. Time was spent observing and interacting with people, including people living at the home who contributed to the findings. Nine members of staff and four relatives spoke with the inspector about the home. The inspector checked all the key standards and some additional standards. The inspector wishes to thank the people at the home for their time, friendliness and co-operation throughout the inspection process. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have information about the home before making a decision, and they have an individual needs assessment prior to moving into the home to ensure that their needs can be met. Intermediate care is not provided at this home. Evidence: We wanted to understand peoples experiences when they decide whether to choose this care home, and what it is like for people if they did decide to move there. We spoke to people at the home about their experiences, and talked to relatives and staff as well. We looked at the information the home give to people and how they assess whether they can meet peoples needs. People felt that they had sufficient written information about the home before choosing, but many had been unable to visit the home because of illness, and felt that the responsibility of choosing a home was left to their relatives. The home said that Care Homes for Older People Page 10 of 26 Evidence: they welcome people visiting before choosing to stay, and could arrange trial stays. One person said, I dont think I got a contract from Southern Cross, I have one from before the take over. I did have enough information about the home before I moved in. The new manager said that she was aware that some of the information required updating, for example about the manager details, and that she would be ensuring people were issued with new contracts as appropriate. Prior to being admitted to the home a nurse carries out a pre-admission assessment and from this they make a decision about whether they could meet their needs. These assessments covered all the required areas. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home have their health and personal care needs met and receive medication safely. Evidence: We wanted to understand how people had their health and personal care needs met. We spoke to people in the home, observed practices in communal areas such as at mealtimes, and looked at records and medication systems. We also used information in surveys returned to us to look at how the staff dealt with things. People told us that generally they felt well cared for, but that sometimes there were not enough staff to see to them when they needed help. Sometimes we noticed that it took a long time for peoples call bells to be answered. There were some concerns raised that staff did not always take the time to communicate with people. The new manager explained that she had made recruitment of staff to vacant posts a priority since she had started at the home, and that she was able to use agencies to ensure there were enough staff on duty. She was confident that the problem was being Care Homes for Older People Page 12 of 26 Evidence: resolved. People living at the home were well presented and appeared calm and relaxed. Personal care tasks were carried out in the privacy of their rooms or bathrooms. Some people chose to stay in bed later in the morning and were given breakfast once they were up. The care plans gave clear instructions for staff to follow, but the progress reports were not very specific about the exact care given that day. Some of the records were not completed accurately such as the personal care record and recreational activity record. This means that staff cannot evidence all the care they have given. There were two examples of peoples health deteriorating and a lack of evidence of how they tried to prevent this, though current care plans were up to date and appropriate. Another issue had previously not been followed through, so although staff had recorded some concerns, these had not been recorded as acted upon. The new manager was in the process of reviewing all care plans to ensure that people were getting the care required, and had identified some of the issues already. She also plans to audit them on a regular basis to keep them up to date. This should improve the care people receive and the quality of the recording to evidence the care given. People were very pleased with the input from the local GP practice who visit the home weekly, and as required. Medication practices were observed to be good and followed the homes policy. The nurses on each floor had to manage two medicine trolleys in order to give out the medicines at mealtimes, which may need to be reviewed. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have some opportunities for social activities and are provided with a varied diet. Evidence: We wanted to understand peoples daily experiences and opportunities to take part in social activities. We observed the routines and the activities taking place, including mealtimes. We spoke to people in the home and looked at the records of activities, routines and meals. People said that they usually liked the meals, that there was a choice, the meals were varied, and that it was usually well cooked and presented. Although there was a choice at the meal time, people did not know what was for lunch beforehand, and were kept waiting at the tables for quite a long time before the meal arrived. Tables were set with cloths, napkins, cutlery, artificial flowers, and condiments, and looked very inviting. During the meal people were quiet and purposeful rather than enthusiastic and sociable. Someone on a soft diet found the food unappetising, with little choice and with limited fish or meat. This information was passed on to the new manager who was planning to review the meals. Care Homes for Older People Page 14 of 26 Evidence: An activities notice board in the entrance hall (not often used by people living in the home) described the different events planned for each week, including activities for each day. These included arts and crafts, exercise, movies, board games, reading group, song time. On the day of the visit the activities organiser was on a course, so activities were limited to those provided by other staff around their usual duties. People said that they did usually enjoy the activities and that there had been a significant improvement lately, but that there were not enough and not enough outings, even just within the local community. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are protected by the policies and procedures in place. Evidence: We wanted to understand how people were protected from abuse or neglect and how the service responds to complaints. We looked at records, policies and procedures and spoke to people living and working at the home. Written procedures for making complaints were displayed in the home, and there was a record of complaints received with action taken. Fifteen complaints were recorded during the past year, with seven relating to care issues, one relating to staffing levels, one due to the attitude of a member of staff, one about inappropriate behaviour of staff, one about a fall and lack of manager support, one about decor and untidyness, one about the transfer of someone, one about equipment, and one about the state of the smoking room and kitchenette. There had been two referrals through adult safeguarding procedures, one of which was ongoing. The majority of staff have attended safeguarding training so that they can recognise and report any concerns they have in order to protect people in their care. People generally liked the staff and felt that they could talk to them about things that concerned them. One person said, the new manager is very good, she comes to see Care Homes for Older People Page 16 of 26 Evidence: me every day, and asks if I am alright. Another person said, before the new manager came, I felt that I wasnt really listened to because things didnt change, but now things are changing. In response to an anonymous comment on a survey returned to us, the home manager and administrator intended to thoroughly audit the monies of people at the home to ensure that they were accurate and all expenditure was accounted for. Random checks of account sheets during the visit did not raise any concerns. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is safe, comfortable and meets their needs. Evidence: We wanted to understand what it was like to live in the premises and whether they were appropriate for the lifestyles of the individuals living there. We were shown around including to some of the bedrooms where we were invited in. Records of maintenance and checks on equipment were seen. People were pleased with their bedrooms and with the facilities of the home. They felt able to choose where they spent their time and attended different parts of the home for different activities. Most people felt that the home was clean and fresh, though some people were concerned about odours from dirty laundry trolleys and hoist slings, and about the general tidyness and cleanliness of bedrooms. Only one area of the home was odourous during the visit and this ceased later in the day following cleaning. The records show that routine checks and maintenance are carried out to ensure equipment is working well and safely. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who are recruited according to procedures and are trained to do their jobs. Evidence: We wanted to understand how staff are recruited and trained to ensure that they could carry out their jobs well. We talked to people living at the home, to visitors and to staff. We checked the recruitment files and the training records to see if procedures had been followed, and noted the comments made on surveys about the staff. People living at the home were generally positive about the staff, and some had good relationships with them. One person commented, the staff (carers) are most helpful. Some people made comments about the amount of staff such as, it would be better if they werent always short staffed. A recent complaint about staffing levels had been addressed by using agency staff and trying to recruit to vacant posts. Examples of call bells taking a long time to answer and people waiting a long time for meals were seen during the visit, and the new manager agreed to monitor and review the staffing levels. The recruitment files demonstrated that the necessary checks and procedures had been followed before someone is recruited in order to safeguard the people at the Care Homes for Older People Page 19 of 26 Evidence: home. The training records showed that people working at the home had regular training in a range of relevant topics to help them carry out their jobs. The manager had a record of which staff had attended and had identified individuals that needed to be updated. Almost 50 of care staff had achieved NVQ level two or above in care, and a further seven people were undertaking the training, so that they can develop in their roles. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and people are protected by the systems put in place. Evidence: We wanted to understand how the home was managed and ensuring a good quality of service for the people living there. We talked to people at the home including the people living there, visitors, staff and the manager. We looked at some records and a survey of people living at the homes views about the service provided. The new manager is Jane Bennet, who was previously a Registered Manager at another home, and is also a Registered Nurse. She had only been in post for about two weeks at the time of the visit , but had done an audit of the service and produced an action plan of the areas that she wanted to improve. She was approachable and friendly and people at the home liked her. People felt that she listened and took action according to what she heard. Staff also liked her and were looking forward to changes being implemented by her. She had immediately commenced recruitment to vacant Care Homes for Older People Page 21 of 26 Evidence: posts, and had brought in agency staff to cover shifts so that the minimum staffing levels were being met. We were given a copy of the survey of peoples views about the service, and shown audits by management about different aspects of care. These show areas of concern or requiring improvement and link to the managers action plan. Records of accidents, complaints and maintenance checks were kept well, and the monies checked were accurate. Staff supervision records were not individualised, but development of these was underway by the new manager. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 13 The care plans should be up to date, progress recorded clearly, and action taken to follow up on any issue identified. To provide evidence that people have received appropriate and timely personal and health care. 30/06/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 9 15 Review the practice of using two medicine trolleys at a time. Review the meals from the individuals perspective, so that people become more involved in the whole experience, and have appropriate choices. Conduct the review of peoples financial accounts kept by the home. Monitor odours and cleanliness of home and consult with people about where specific problems may be. Monitor and review staffing levels to ensure peoples needs Page 24 of 26 3 4 5 18 26 27 Care Homes for Older People are met. Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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