Inspection on 17/03/05 for Chapel Lodge Nursing Home

CARE HOMES FOR OLDER PEOPLEChapel Lodge Nursing Home105 Station Road Chapeltown Sheffield South Yorkshire S35 2XFLead InspectorMs Stephanie Kenning Key Unannounced Inspection 17th March 2008 09:30X10015.docVersion 1.40Page 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 organisationReader InformationDocument 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.ukInternet addressChapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 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 Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 3 SERVICE INFORMATIONName of service Chapel Lodge Nursing HomeAddress105 Station Road Chapeltown Sheffield South Yorkshire S35 2XF 0114 257 8727 0114 257 8728 chapel@schealthcare.co.ukTelephone 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)Southern Cross Healthcare (Focus) LimitedMrs Alison Louise Lingard Care Home 63Category(ies) of Old age, not falling within any other category registration, with number (63) of placesChapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 4 SERVICE INFORMATIONConditions of registration: 1. 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 admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places 63. The maximum number of service users who may be accommodated is 63. N/A2.Date of last inspectionBrief Description of the Service: 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. 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 washbasin. 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 £623, depending on a needs assessment, and do not include chiropody, hairdressing, newspapers, dental, optical, toiletries and outings. This information was provided on the 17th March 2008. 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.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 5 SUMMARYThis is an overview of what the inspector found during the inspection.The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomesSince the new registration in 2007 a record has been kept of notified incidents and events at the home. Prior to the recent unannounced visit of March 17th 2008, information was provided in The Annual Quality Assurance Assessment, completed by the manager. The site visit on March 17th, by Stephanie Kenning, Regulation Inspector, from 9.30am to 5.30pm, and Heather Hudson, Expert by Experience, from 11am to 2pm, also contributed to this report. The home was closed from June to December 2007 following flooding from the adjacent river and to refurbish the building. During the visit the inspector and Expert by Experience spoke to 11 people who use the service, 5 relatives, 5 staff and the manager, and would like to thank all for their openness, and contribution to the findings. The inspector was pleased to note that people spoke positively of the ongoing support provided by the staff. Of particular note was the way in which staff responded to the flooding emergency in order to ensure the safety of the people living in the home. A number of records were looked at, which included, medication records, three care plans of people currently at the home, and menus. Records relating to staff training and the homes quality assurance systems were also checked. Several areas of the building were also seen, and observation of activities and meals served. Feedback on the findings was given to the manager before the inspector left the home. Seven complaints had been dealt with in the past 3 months, covering various issues including transport, flood damaged property, diet, activities, items missing, care practices, and fees. Records show that they were responded to quickly with satisfactory outcomes, apart from the ones being dealt with by social services through safeguarding procedures. The Provider and senior management of the company were aware of these issues at this home and were visiting frequently to assist and support the manager. A Nurse Advisor for the company was working with the staff to raise standards. Since reopening at Christmas the rate of admissions has been high, and the manager felt this may have affected the service. The inspector would like to thank everyone involved in the inspection for their help and support.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 6 What the service does well:People living in and visiting the home felt welcome and included in events at the home. There are plans for relatives meetings, and an active residents committee, to help obtain the views of people using the service. There is an annual satisfaction survey that also obtains the views of people using the service. This was in the process of being sent out during March. A thorough pre-admission assesment is completed so that the placement is appropriate and people know that their needs can be met. Basic personal and health care is carried out well, and medication is managed by qualified staff who have had appropriate training. Complaints have been used to help improve the service, and they have responded appropriately to any areas that involve abuse. The home is only 10 years old and was purpose built. It has recently been refurbished and it is kept neat and tidy, clean and odour free. There are safe grounds for people to walk in, and work has been done to improve the safety including the erection of a flood barrier by the river. The menus have a comprehensive range of nutitious options available, and people living in the home praised the food. They have recruited an experienced activities organiser and added to the activities programme, providing more relevant and appropriate activities in response to the people using the service.What has improved since the last inspection?This is the first inspection under this registration.What they could do better:They could make improvements in the way records are written to reflect what has happened to individuals each day. The home should fully implement the choices on the menus so that they are available to all. Although the home generally meets the minimum staffing levels required, they need to ensure sufficient staff to improve and develop the home, and to facilitate good communication between staff, for the wellbeing of people in their care. The planned programme of training identified must be carried out to ensure all staff members are up to date in the skills and knowledge required to do their job. The staff supervision system should be fully implemented to help develop the staff in the roles.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 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. The summary of this inspection report can be made available in other formats on request.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 8 DETAILS OF INSPECTOR FINDINGSCONTENTSChoice 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 InspectionChapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 9 Choice of HomeThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 1, 2, 3, 4 and 5. Intermediate care is not provided at this home. People do not move in to the home until a full needs assessment has been undertaken and the home can confirm they can meet the needs of that individual. EVIDENCE: The written information provided about the home including the service user guide was up to date and followed the Southern Cross format. It stated that information was also available on audio- cassette. The information explains the system for looking after small amounts of money, and when individual bank accounts will be opened. Copies of the service user guide were seen in bedrooms and one person showed us their copy, saying that it had useful information in it. Terms and conditions of residence are provided and contractsChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 10 showing charges and what service people will receive. This helps people know what to expect when they go to live at the home. There was a lot of information on the notice boards around the home and in the entrance, that explained about the home and events going on there. A dedicated team of staff deal with enquiries to the home so that the information they give is up to date and accurate. People usually have an assessment of their needs prior to living at the home, and the manager sends them a letter saying whether the home can meet those needs or not. Copies of these assessments were seen in the care plan files, and they covered all the required areas. Many of the people that had recently come to live at the home had come from hospital and had not visited the home beforehand, however relatives usually visited on their behalf, and made choices between different homes. One person had visited the home and decided to stay for a trial period. She found that she enjoyed living there and did not return home. She said that, ‘I would be very upset if I had to go back home’. Most people were pleased with the home and said that their needs were met. There were some people that were trying to sort out problems such as food choices, that they hoped were just ‘teething troubles’. Most people found the process of moving to the home aided by the staff being supportive on their arrival. People spoke of their helpfulness in finding the right equipment, and making sure they had everything they needed. There were a lot of personal items in the bedrooms that people had brought from home, and this helped them feel more at home. Since the home reopened at Christmas more than 50 people had come back or been admitted to the home. Despite allowing an additional member of staff to cope with this, the manager felt that this might have temporarily affected the service provided at times. The company had provided an advisor to assist the manager in raising standards, and work on this was in progress during the visit.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 11 Health and Personal CareThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 7, 8, 9,10 and 11. People’s individual personal and health care needs are met to a basic level, staff support them in this, and respect their privacy. Medication systems follow clear guidelines that promote the safety of residents, and allow some people to be independent. EVIDENCE: The care plans of three people were looked at in detail during the visit, and they were found to be completed well with actions that linked to identified needs in assessments and risk assessments. They covered the activities of daily living and there were specific plans, for example, wound care. Some of the writing was difficult to read, which would make it hard for other staff to follow. Some of the information recorded in the daily records was poor, as it did not specify what had happened to the person, but gave a broad statement, such as ‘safety maintained’. Even where people had identified problems, forChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 12 example with swallowing and nutrition, the recording of the actual intake of food was minimal. This made it difficult to judge if the correct care had been given, and if it was appropriate for that person. Verbally staff members were able to describe the care that person had received, and knew a lot about the people they were caring for. They were seen speaking to people respectfully and carried out all personal care privately. The home have people registered with five different GP practices, though people coming to live there from outside the local area are allocated a GP through the PCT, rather than choosing their own. There are some difficulties accessing dental care that people with mobility problems can get to, and again the PCT are involved in finding dental care. The community nursing service are involved in the care of people receiving residential care, and were visiting someone for wound care during the visit. Five people had pressure sores of different grades, three of which were present on admission to the home. All were being treated and a variety of pressure relief aids were being used. Visits and communications with others were recorded in individual records. Some people chose to stay at the home for end of life care and staff received training in this specialist area. People living at the home were happy with the way most staff gave their care, but some were concerned about a lack of consistency and information not always getting passed on. Management at the home felt that this might be linked to the rapid increase in staff members to care for the rapidly increasing number of people living at the home. They were aware that this had caused some problems and were working at improving the quality of service through training and looking at practices. A questionnaire had been sent to people and their relatives to get feedback about the service and to hopefully identify any other areas that need looking at. The home uses the standard medication policies and procedures of Southern Cross, and staff felt that the systems worked well. A nurse was observed giving out the lunchtime medications and she followed the procedures, ensuring the safety of the people in her care. The manager audits the medication each month and has identified some minor areas for improvement.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 13 Daily Life and Social ActivitiesThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 12, 13, 14, and 15. People are able to make choices about their lifestyle and activities, and a good range of activities is provided. People usually enjoy the meals and the home is developing the range of choices including more nutritious options. EVIDENCE: There was a good range of activities offered and evidence of a variety over a month was displayed on a large informative notice board. Activity rooms are provided, one small and another larger, and during the visit 6 people were making Easter bonnets. Other activities included a juggling pianist, remembering the old days, knitting, baking, jigsaws, a reading group on a one to one basis, smell touch and taste, films, and discussions. Other amenities listed on the board are hairdressing, communion, and walking. Use of the company minibus is available for outings and there was evidence of meals out and tea dances at Meadowhall. People spending time in their rooms have some attention every day, but as there is only one activity organiser this is limited. People said that they would like to do more outings and have more communityChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 14 contact, as there is a good range of facilities in the area. This was also an area identified by the manager for further development. People generally enjoyed the meals and the dining areas were spacious and nicely presented to help the experience. Menus were displayed in the dining rooms and appeared to offer a good range of choices, with healthy options, called the nutmeg system. However, it was observed during the afternoon and at teatime that not all the menu options were available or promoted by staff therefore limiting the excellent menu choices. This was said to be a new and developing system, introduced to increase the range and nutritional content, and management felt that it needed more input to be fully implemented. Several visitors were present, and they felt welcomed, and involved. Most had high praise for the staff and the care given though some were less pleased, wanting better communication and regular carers. A residents and relatives meeting was planned for later that week, for people to raise issues and put forward suggestions. Relatives were able to make drinks for themselves and people living at the home in the kitchenette, helping them to feel involved.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 15 Complaints and ProtectionThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 16 and 18. People who use the service are able to express their concerns, that they will be listened to, and action taken.EVIDENCE: The company has a comprehensive range of policies and procedures, including a well publicised complaints procedure available to all people using the service in the individual service user guides. The policy is also displayed on the notice board for visitors to see. People working at the home know how to deal with a complaint and have had training in recognising abuse and what to do if they suspect it is happening. This helps to protect the people using the service. Seven complaints had been dealt with in the past 3 months, covering various issues including transport, flood damaged property, diet, activities, items missing, care practices, and fees. Records show that they were responded to quickly with satisfactory outcomes, apart from the ones being dealt with by social services through safeguarding procedures. The Provider and senior management of the company were aware of these issues at this home and were visiting frequently to assist and support the manager. A Nurse Advisor for the company was working with the staff to raise standards. SinceChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 16 reopening at Christmas the rate of admissions has been high, and the manager felt this may have affected the service.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 17 EnvironmentThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 19, 20, 21, 22, 23, 24, 25 and 26. People live in a safe, well maintained, clean and comfortable home. It is suitable for the specific needs of the people that live there. EVIDENCE: 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. The building has two floors accessed by a shaft lift and several staircases. Keypads restrict the access around some of the building helping to keep someChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 18 people safe. All the bedrooms are single, but of a good size with an en-suite toilet and wash- basin. People had personalised their rooms with a variety of items that helped them to feel at home. 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. There was a good range of aids to mobility, including hoists and bath hoists, and pressure relief equipment, to promote wellbeing. The décor and furnishings were in good condition and the home was clean and fresh. 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. In addition to internal refurbishment the work included dredging the river to enable it to flow better and putting up a flood barrier in the garden in the area most at risk. The gardens have also been redone and new seating and plants provided for the use of people living in the home.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 19 StaffingThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 27, 28, 29 and 30. People are generally satisfied with the care they receive, and most staff members are well trained and competent. EVIDENCE: People were generally satisfied with the care they received to meet their needs, but there were times when they have needed to wait a short time for staff support and attention. The rotas of staff show that as the number of people living at the home increased then the number of staff increased to correspond. In addition there had been an additional member of staff in acknowledgement of the intense work involved in admitting people to the home and helping them to settle in. During the ten weeks prior to the visit about fifty people were admitted or readmitted to the home, and the manager of the home feels that this might have been too many, as some problems have occurred with standards of care not being upheld. The company, who have been working to improve standards, has acknowledged this. An advisor was working with the home to audit care practices and do training to improve them. Admissions to the home had been stopped temporarily by social services whilst they investigated concerns.Chapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 20 Recruitment follows the company procedures and includes relevant checks to safeguard people in their care. After recruitment all staff members complete an induction period that includes training, and there is additional training offered according to job role. There are about 45 of staff with an NVQ level two or above in care, with more staff working towards the qualification. The target of 50 of carers should therefore be met easily, and this shows a commitment to the development of staff. The manager was also aware of some gaps in the training programme and had plans to deal with this.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 21 Management and AdministrationThe 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. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We looked at outcomes for standards 31, 32, 33, 34, 35, 36, 37 and 38. The management of the home have implemented changes and systems to improve the lives of people living in the home. EVIDENCE: Alison Lingard, who has the required qualifications and experience, manages the home. She is required by Southern Cross to carry out audits in the home to ensure that the home is operating well, and showed evidence of this at the visit. There is a monthly audit that covers all areas of home management and gives actions required. In addition are care plan, medication and kitchen audits, all of which identified some areas for improvement. This showed thatChapel Lodge Nursing Home DS0000069698.V360647.R01.S.doc Version 5.2 Page 22 she was being pro-active in trying to improve the service for the people at the home. A support manager Wendy Averill has been working at the home auditing, training and doing general care awareness with staff to address some of the concerns that arose recently. The operations manager Terry Peel supported the manager and acknowledged that the period of rapid admissions might have affected the quality of care, but that they were addressing the concerns as quickly as possible. The people using the service were clear that if they had concerns they would feel able to take them to a member of staff or to the manager, whom they said was approachable. The service has a comprehensive range of policies and procedures that were available for all to read in files in the hallway, and these are discussed in staff meetings. Staff received feedback on their work during supervision sessions, though these were not fully implemented following the reopening of the home. The manager stated on the AQAA that it was an area requiring further development. The audits included all aspects of health and safety practice, and further evidence was given of checks, for example fire safety, showing that they give safety a high priority. There is a regular meeting of health and safety representatives in the home, where issues are discussed and an action plan agreed. Records are generally of a good standard and are up to date, except for the daily records of individuals as reported in section two. Accurate records were kept of money being looked after on behalf of people in the home.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 23 SCORING OF OUTCOMESThis 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 applicableCHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 263 3 3 3 3 N/AHEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 33 3 3 3 3 3 3 3STAFFING Standard No Score 27 2 28 3 29 3 30 2MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score3 3 3 3 3 2 2 3Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 24 Are there any outstanding requirements from the last inspection?N/ASTATUTORY 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, 17 Requirement The daily records within individual records should be more specific about the care given and the progress of that person. Monitor staffing levels to ensure there are adequate numbers to meet the needs of people at the home. Carry out planned training to ensure that all staff receive the required training. Timescale for action 01/05/082.OP271801/05/083.OP301801/07/08RECOMMENDATIONS 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 OP15 OP36 Good Practice Recommendations Fully implement the choices on menus. Fully implement supervisions for staff.Chapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCIChapel Lodge Nursing HomeDS0000069698.V360647.R01.S.docVersion 5.2Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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