Inspection on 07/05/08 for Chaplin Lodge

This inspection was carried out on 7th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chaplin Lodge 14/05/07

Chaplin Lodge 22/05/06

Chaplin Lodge 07/02/06

Chaplin Lodge 09/09/05

Chaplin Lodge 08/02/05

Chaplin Lodge 24/06/04

Chaplin Lodge 04/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Chaplin Lodge Nevendon Road Wickford Essex SS12 0QH Lead Inspector Mrs Sharon Lacey Unannounced Inspection 7th May 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaplin Lodge Address Nevendon Road Wickford Essex SS12 0QH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01268 733699 01268 570602 chaplinlodge@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Vacant Care Home 66 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (66) of places Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Personal care to be provided to no more than 66 service users over 65 years of age. Total number of service users for whom personal care is to be provided shall not exceed 66. Service users with dementia to be accommodated in Parkview Unit only. The home may provide accommodation & personal care for up to a maximum of three people who are over the age of 50 years and under the age of 65 years. 14th May 2007 Date of last inspection Brief Description of the Service: Chaplin Lodge is a care home which provides personal care without nursing for up to a maximum of sixty-six older people. They are registered to provide care for up to a maximum of eighteen people who have a diagnosis of dementia. Accommodation is provided in the main area of the house over two floors, which is accessed via a passenger lift. Residents have access to a number of communal areas including lounge and dining rooms. The home is situated in a busy residential area close to Wickford town centre. The cost of a place at the home is £447.57 per week. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was a routine unannounced inspection, which took place over eight hours. The key standards were inspected, but also evidence was gained on some of the other National Minimum Standards. A tour of the home was completed and an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Chaplin Lodge; information gained when residents first come to the home; how information is given to staff on the care required, the facilities and environment of the home and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. An Annual Quality Assurance Assessment (AQQA) was sent to us by the Manager. The AQQA is a self-assessment that focuses on how well outcomes are being met for people using the service. It provides numerical information about the service and also how the service intends to improve over the next 12 months. Information from this document has also been used in this report where appropriate. During a tour of the home a number of residents were spoken to about their life experiences at Chaplin Lodge. Some of the other residents approached were unable to express their thoughts and feelings, but were observed during the day interacting with staff. Questionnaires were sent out to residents, relatives and also health care professionals. Eleven residents, two relatives and one health care professional returned completed questionnaires and feedback from these has been included in the report. Most staff members were spoken with informally during the inspection and any feedback has been included as part of the report. Staff questionnaires were also distributed, but only one was received back. At the end of the day the inspection was discussed with the manager and operations manager and advice and guidance was given regarding the findings. What the service does well: Prospective residents have plenty of information made available to them about the home, which enables them or their relative to make an informed choice. A copy of the service users guide is given during the assessment process. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 6 There is an admission process and all new residents are visited before they come into Chaplin Lodge to ensure their care needs can be met. Care plans are completed around the care needs of the individual and included details on how the care is to be provided. Staff were observed during the day interacting with residents in a caring and appropriate way. The management of the home have an open approach to complaints and are keen to improve this further. Residents are well informed on how to make a complaint and who to raise it with. The manager of Chaplin Lodge has the experience and knowledge of managing residential homes. There are clear lines of accountability within the home and also external management support. What has improved since the last inspection? What they could do better: The team at the home need to ensure that residents receive their medication on time so that their health is not adversely affected. Some of the areas around the home are beginning to look tired and in need of decoration. Some carpets are beginning to look very tired and a slight odour was detected in the foyer area and also some corridors. This needs attention in order to make the environment nicer to live in. There remain shortfalls in relation to staff training and the management of the home need to address this to ensure that residents care needs can be met in full and that they are as safe as possible. The recruitment procedures in the home are not robust enough to ensure resident safety and need to improve to ensure all aspects of recruitment are covered. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Chaplin Lodge has sufficient information available to enable people to make a choice about living at Chaplin Lodge. A full needs assessment is undertaken prior to people being admitted to help ensure that their care needs can be met at the home. EVIDENCE: A copy of the service users guide and statement of purpose could be found in the foyer. The manager stated that both documents had been updated, but there was no review date to indicate when this had occurred, although the information was correct. The manager confirmed that new and prospective residents are given copies of the service uses guide during the assessment process, but this is not routinely recorded. Feedback from the questionnaires confirm that eight residents felt they had received enough information about Chaplin Lodge before making the choice to move in. Both documents are also available on audio cassette. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 10 There is an admission process and the manager confirmed that all new residents are visited before they come into Chaplin Lodge to ensure their care needs can be met. Three residents’ files were inspected and all contained a full assessment. The assessment form consisted of tick boxes, which highlighted dependency levels and covered all areas listed in standard three of the National Minimum Standards. The manager explained that residents are given a contract after they had been at the home for at least six weeks. Feedback from the questionnaires confirmed that seven residents had received a contract and four stated they had not. The manager stated that all new residents are encouraged to spend a day at the home. It was noted that in the statement of purpose it had an invitation to visit the home and perhaps a stay from meal will be offered. The manager confirmed that trial visits that occur are recorded. Staff had received training, although some updates are required, but generally staff had the knowledge and experience to care for their present residents. Seven residents that responded to the questionnaires reported that they always received the care and support they needed; whilst four others stated they usually did. All confirmed that staff listened and acted on what they asked. The AQQA submitted confirmed that brochures are sent out to prospective residents, experienced staff carry out pre admission assessments and all prospective residents are written to, to confirm that the staff employed at Chaplin Lodge are able to meet their needs. One area that they would like to improve is in connection to introducing a guest day for prospective residents and trying to arrange for local authorities to fund this. Also, they would like to allocate key workers to residents before they come into the home, to enable them to identify a named staff member and make them feel more welcome. Intermediate care is not provided at his home. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain sufficient information for staff to ensure residents care needs are met. Medication practices at the home are well managed and ensure that residents are kept safe. EVIDENCE: Three residents’ files were inspected and all contained a care plan, which had been completed around the care needs of the individual and included details on how the care is to be provided. Written evidence was available that residents had been involved in the care planning process and included religious, and individual needs. The manager confirmed that care plans are reviewed monthly and evidence was seen of this on resident files. The pre-admission draft care plan was informative form, easy to read and provided staff with clear information on the care required. Daily observations were well recorded and risk assessments were also in place. Nine residents confirmed that they always received a medical support they needed, whilst two stated they usually did. The three files inspected Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 12 contained clear evidence to indicate the residents are supported and have access to a variety of health care resources (GP, District Nurse, hospital appointments etc). Visits to the dentist are arranged when needed. On speaking to one district nurse who was visiting the home, she stated they are very good to the residents. The manager confirmed that three residents had pressure sores. During a tour the home there was evidence that specialist equipment was being used to try and improve these and service users were also receiving regular visits from the district nurse. None of the staff had received training in pressure care, but the Operations Manager stated that this was in the process of being arranged. It was noted during a tour of the home that some residents had fluid charts in their rooms to record their fluid intake. On viewing these it was apparent that some had not been correctly completed and only contained very ad hoc information, so it was not clear if residents had received sufficient fluid intake. This was brought to the managers attention. There is a policy on the Administration of Medicines, but this was not viewed during this inspection. Medication at the home is managed through a monitored dosage system (blister packs). It was noted that on the day of the inspection that the breakfast medication was still being administered at 11:15 a.m, which is quite late; especially when some residents would be receiving medication at the lunchtime meal and insufficient time may would be between doses.. As part of the inspection process the deputy manager was observed administering the lunchtime medication and good practice was observed. Bottles of medication had been dated when opened, storage was good, there were photos of residents to assist in identification and records sampled were well maintained with no anomalies noted. Records showed that all staff that administer medication had completed training. It was recommended to the manager that ear and eye drops should be provided away from the dining table to ensure residence dignity. Medication that is given as and when required did not have guidance to staff on when this may be needed, although the Operations Manager stated that there was a protocol for as and when medication. It was established during the inspection, that the issue of privacy and dignity is covered in a number of ways. The statement of purpose and philosophy of care cover these issues and these could be found in the foyer. The manager confirmed that privacy and dignity is part of the staffs induction. Staff were observed during the day interacting with residents in a caring and appropriate way. It was pointed out to the manager that one resident was noted to have very long and dirty fingernails. The inspector was advised that this was the residents’ choice, but they had recently requested for these to be cut and cleaned. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 13 The manager stated that they try to ensure residents are able to stay at the home in familiar surroundings for as long as they are able to provide appropriate care. There is a policy and procedure on the care of the dying and it is also part of the care plan. The manager stated that some staff had received training on death and dying. One relative who was spoken to during the inspection stated that her mum was recently ill and she chose for her to stay at the home and was very happy that the care she received. The AQQA confirmed that all residents have a pre admission draft care plan before coming into the home. Areas that they wish to improve included building on the death and dying care plans and wishes of new residents and ensuring this is clearly recorded. It is also hoped they will continue to maintain and improve the quality of care and provision of advocacy for their residents. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given the opportunity to take part in a variety of activities, both as an individual and as a group to ensure they receive stimulation within the home. The food within the home is of a satisfactory quality and meets the dietary needs of the people who use the service. EVIDENCE: Chaplin Lodge has two activity coordinators who work with the residents. A five week program of activities could be found in the home’s foyer. This included board games, card games, bingo, Dominos, cake and biscuit decorating, hand massage, flower arranging, PAT dog and individual outings. Details in the daily activities notes included pictures of residents participating in activities and also a list of residents who had taken part. A party had been recently organised to help celebrate VE day. On the day of the inspection one resident was observed going out with an activities coordinator and they were going to the shops to have coffee. The resident stated they are looking after me well. Comments from the questionnaires included five residents stating that activities were always arranged at the home, while three said they usually were and two added they sometimes were. The manager stated that staff had been attending training Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 15 on Yesterday, Tomorrow and Today, which would advise staff on appropriate activities for residents who have dementia. The activities coordinators also arrange resident meetings within the home. The manager has an open visiting policy, but it states in the service user guide that if relatives arrived during mealtimes that they will made comfortable until the mealtime is finished, this is to ensure other residents privacy is upheld. Visitors were noted to come and go throughout the day. One relative spoken to during the inspection stated that they were always made to feel very welcome and had often been offered a meal at the home. There is no specific visitors room, but whilst touring the home it was clear that there were quiet areas that could be used. It states in the service user guide that autonomy and choice is encouraged and on discussion with the manager it was established that routines within the home were fairly flexible and choices provided in meals, time to get up and go to bed, clothes, bath times etc. Chaplin Lodge is registered with the data protection, but no details could be found to advise residents that they can have access to their files. There were details of advocacy services in the service user guide. The menu had recently been changed and was still in its trial period. On the day of the inspection, residents had a choice of two hot meals at lunchtime and a further choice of two meals at teatime. There is a cooked breakfast every day and one resident confirmed that they had had porridge, grapefruit and egg and bacon for breakfast. The menu in the foyer was in very small writing and residents would have some difficulties reading this. It was noted that there were no details of the menu in the dining areas and of the eight residents and one relative spoken to during lunchtime, none were aware of what was available for dinner. There were mixed comments regarding the food, these included food is very good, we dont leave any, the food is very nice here and the food is not as good, we are disappointed that they have stopped the mixed grill. When asked on the questionnaires whether they liked the food at the home, seven resident stated always, three said usually and one said sometimes, but these comments were gained before the new menu had been implemented. Concerns were raised that the new menu had too many repeated choices of minced meat dishes and pies. On viewing the menu it was apparent that minced meat had been used up to three times in one week. The manager confirmed that nutritional records are kept, but these were not inspected during this inspection. It states the service user guide stated snacks and soft drinks are available between meals and evidence of this was seen during the inspection. Fresh fruit was also on offer. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 16 Dining tables were noted to have tablecloths, cruets, glasses, paper napkins and flowers in vases. Staff were observed assisting feeding residents who needed assistance and this was done with dignity and respect. Residents were also offered more food before their plates were cleared. One resident had chosen to eat their dinner in their room and a staff member was observed taking it down on a tray The kitchen was inspected and noted to be clean and tidy. There is a good supply of fresh vegetables and fruit. The AQQA submitted confirmed that the manager hoped to develop their activity coordinators by sending them on more creative activities for older people. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place to enable residents and relatives to raise concerns or issues and be confident that their concerns will be acted upon. Policies, procedures and training are in place, to help ensure residents are kept safe. EVIDENCE: There is clear written guidance in the service user guide and the statement of purpose on how relatives and residents can make complaints. Details of the complaints procedure could also be found in the homes foyer. The complaints folder contained a set of forms, which included details of the complaint, investigation and whether the outcome was satisfactory. There was also a compliment file. Only one complaint had been received by the CSCI, and this was still in the process of being investigated by the Manager. Feedback from the questionnaires confirmed that ten residents knew how to make a complaint, and eight stated they knew who to speak to if they were not happy. Staff spoken to had an understanding of safeguarding adults on whistle blowing. Details of whistle blowing could also be found in the staff cloakroom. Staff training records showed that most staff had received training in this subject, but four needed training or an update. One safeguarding referral had been made since the last inspection and is still in the process of being investigated. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 18 The AQQA confirmed that Chaplin Lodge has a complaints procedure with specified timescales. The manager intends to start the logging verbal complaints and plans to continue to maintain improvements when dealing with complaints. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there, but is in need of some decoration and maintenance to ensure it offers a clean, safe and homely place for residents. EVIDENCE: A tour of the premises was undertaken. The location and layout of the home is suitable for residents needs and is generally comfortable. The manager stated that some decoration had occurred since the last inspection, and it was noted that the dining area had recently been painted. Some of the other areas of the accommodation was beginning to look tired and in need of decoration. Areas of concern included a large crack in an upstairs wall, scuffs on the hall walls and stair ways, kitchen cupboard doors had fallen off in one lounge/diner and there was loose grey tape on the carpet to try and stop it from coming up. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 20 There were sufficient dining and lounge areas around the home. Some carpets were beginning to look very tired and a slight odour was detected in the foyer area and also some corridors. A number of residents’ bedrooms were viewed and it was noted these had been furnished with personal items. Some residents’ bedroom doors had not got locks fitted, and there were holes where these once were. Water temperatures were checked in three residents bedrooms and found to be within acceptable limits. Radiators had been fitted with thermostatic valves and windows had restrictors fitted. There was domestic lighting throughout the home, which provides a homely feel. The staff team had use of hoists, hand rails, pressure mattresses and bath equipment. There were bathrooms and toilets around the home, which were clean and tidy. Residents had the choice of using either a bath or a shower. It was noted that one shower was out of use due to being used for the storage of laundry and also chemical bags. During the tour the home it was noted that not all bathrooms and toilets had paper hand towels and soap. The training matrix showed that most staff had received infection control training, but seven staff still needed to attend. Staff were seen using disposable aprons. It was also bought to the managers attention that during a tour of the home the sluice was found to be open (the lock was broken) and this had been used to store chemicals, which could be harmful to residents. Chaplin Lodge has a garden area in the middle of the home. This had garden chairs and tables and had been paved to make easy access for wheelchairs and walking frames. On the day of the inspection the weather was quite nice and one gentleman was sitting in the garden. A water tank had been leaking in the doorway of the garden and made it dangerous for residents to use this exit, one resident stated this had been like this for some time. There were also raised flower beds, but it was noted that these had been neglected and had large stinging nettles amongst other weeds. The garden also contained a large open fishpond, which the manager was advised to ensure a risk assessment had been completed, to ensure resident safety. The AQAA stated that Chaplin Lodge has a full-time maintenance person who deals with minor repairs. It also confirmed that the home has a full-time housekeeper with a comprehensive cleaning programme to keep the home clean and free from unpleasant odours. From the evidence gathered during the inspection, this was not always so. It also stated that within the next 12 months it is planned to redecorate all communal areas and replace some bedroom furniture and vanity units in residents’ rooms. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare of people using the service. Staff have sufficient training to ensure they have the skills and knowledge to provide the care to present residents, but some staff need updates to ensure their practices are kept upto-date. EVIDENCE: There are seven care staff and three seniors on duty for both the morning and the afternoon shift. At night there are four care staff and one senior on duty. The home also has a manager, a deputy manager, an administrator, a maintenance man, two activity coordinators and a number of domestic staff. On the day of the inspection three staff were mainly observed in each lounge, but at 2 p.m. it was noted that one lounge only had one staff member present. During the inspection, staff were observed assisting residents appropriately, encouraging them and having general social contact. Four residents stated that staff were usually available when they needed them and seven stated they always were. Comments gained on the day of the inspection included could not wish the better girls and they work very hard. One relative stated my mum has been settled in Chaplin Lodge for almost 6 years. The carers have helped me through some difficulties, with their care and friendship. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 22 There is recruitment policy and procedure and it is the managers responsibility to ensure that all the information required is gained before the new staff member starts work within the home. The files of three recently recruited staff were inspected. Most of the recruitment procedure had been followed, although it was noted that one staff members criminal declaration had not been fully completed. Also all three files did not contain a full employment history and where there were gaps between employment that had not been investigated and recorded. One staff member had a reference from a previous employer, but it was noted that this had not been included as part of their employment history. The present application form did not have space for the applicant to record their date of birth, which often made it difficult to establish whether a full employment history had been gained without going through other documentation. All three staff files contained written evidence that an induction had taken place. The manager confirmed that the induction used is in line with the Skills for Care induction. The manager reported that she is still working towards 50 of staff having achieved NVQ training. At present six care staff have achieved NVQ 2 and three have achieved NVQ 3. There were also eight staff working towards the NVQ 2 and three more doing NVQ 3. The manager had produced a training matrix, which clearly showed all the training that staff had completed and where updates were required. This record evidenced that this included fire safety, fire drills, food hygiene, moving and handling, COSHH, health and safety, safeguarding, infection control, nutrition and medication. On the training matrix that was supplied during the inspection, it was noted that some staff required updates. Three required fire safety and food hygiene training, 12 needed moving and handling training and four required COSHH and health and safety training. Generally staff had the skills and knowledge required for their role as a carer. Staff spoken to confirmed they had been offered training. The AQAA confirmed that there was a robust recruitment procedure and new staff are not employed until cleared by The Criminal Records Bureau and in receipt of two satisfactory references. Evidence from the inspection highlighted that this had not always been followed. Chaplin Lodge is still in the process of recruiting more staff, and would like to build up a pool of bank staff to limit/stop the use of any agency staff. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others are consulted to gain their views on the quality of the service provided by staff and management, so improvements can be made. Safety checks are completed to ensure there is a safe environment for residents and staff EVIDENCE: The manager of Chaplin Lodge has the experience and knowledge of managing residential homes. She has only been employed at the home three months and has not yet applied to us for registration. There are clear lines of accountability within the home and also external management support. Both staff and residents spoken to during the inspection felt the manager was approachable. She provided a surgery once a week for any relatives who may Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 24 have concerns and also resident, relatives and staff meetings had been organised. There were policies and procedures in place for residents’ monies, but these could not be checked due to the computer system being down during the inspection. The statement of purpose and service users guide provides information regarding finances. Residents’ finances are also checked by the Operations Manager when she does her monthly visits to complete her regulation 26 reports. Chaplin Lodge has systems in place to monitor the quality of the services they provide. The Operations Manager visits the home on a regular basis to complete an audit report. As the home is contracting with Essex County Council, annual visits are made and a copy of the most recent report could be found in the foyer. The manager also has to complete monthly audits, which are sent the Operations Manager. Service users and relatives views are also gained through sending out questionnaires and collating the responses, to highlight areas that may need attention. Chaplin Lodge has a clear policy and procedure for the supervision of staff. The manager had introduced a supervision matrix, which showed when staff had received some form of supervision. Although there was some evidence that supervision had taken place, it was established with the manager that this is an area that needs to be developed further. Staff and residents files are kept secure and Chaplin Lodge are registered with the Data Protection Act. Residents can have access to their files if requested. Regular checks on gas appliances, lift, PAT testing, water chlorination, fire extinguishers, nurse call systems and water temperatures have taken place. Appropriate insurance certificates were seen and in order. Head office also produced a business plan for the home each year. It was noted that the registration certificate in the foyer needed to be updated due to the previous manager still being listed. Accident book was viewed and in order. Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 26 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 OP19 Regulation 23(2)(b) Requirement The premises and garden must be kept in a good state of repair externally and internally and all parts of the care home must be kept clean and reasonably decorated. This is to ensure it is a safe and healthy environment for residents. Suitable arrangements should be in place to ensure the prevention of infection and the spread of infection at the care home. This must include suitable training for staff on infection control and regular updates to ensure the safety and welfare of residents. A full employment history should be gained for all new applicants and that any gaps in employment must be discussed and clearly recorded. This is to ensure there are systems in place to safeguard residents and they are not put at risk. Timescale for action 30/11/08 2. OP26 13 (3) 31/07/08 3. OP29 19(1)(b) Schedule 2 (6) 30/06/08 Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 27 4. OP30 18 (1) (c)(i) All staff who work at the home must receive training for the roles they are to perform. Staff must be provided with training and updates which are relevant to their work and ensures the health and safety of residents. This is with regard to outstanding training and training in moving and handling, safeguarding, infection control etc. Previous timescale of 30/07/07 not met. New timescale given. 31/07/08 5. OP36 18 (2) (a) Staff should receive appropriate supervision to enable them to complete their role as a carer in a safe and competent manner. 30/06/08 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 OP1 Good Practice Recommendations It is recommended that you add a review date to your statement of purpose and service user guide to provide clear evidence when this has been done. It is recommended that you record when residents are given copies of the statement of purpose and service user guide. Please ensure that where it is assessed that fluid intake sheets are needed to monitor residents health, these should be correctly completed by staff to provide the required evidence. 2. OP1 3. OP8 Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 28 4. OP9 It is recommended that guidance is given to staff to help them establish when as and when required medication may be needed by residents or not. It is recommended that staff are made aware of good practice when administering eye drops and ear drops, to ensure residents dignity is respected. Please ensure that breakfast medication is completed by an appropriate time and that it does not interfere on medication given at lunchtime ie by ensuring there is sufficient time between each dose. It is recommended that residents are made aware that they can have access to their files and are given guidance on how they can achieve this. It is recommended that details of menus are placed in the dining room to advise residents of what meals are available for the day. Also written information should be made larger so residents can read this. It is recommended that the new menus are reviewed after a trial period to ensure they meet residents choice. It is recommended staff receive supervision at least six times a year and this is clearly recorded. 5. OP9 6. OP9 7. OP14 8. OP15 9 10. OP15 OP36 Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 CSCI Chaplin Lodge DS0000018079.V363900.R01.S.doc Version 5.2 Page 30 - 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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