Inspection on 30/12/05 for Chase House Ltd

This inspection was carried out on 30th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chase House Ltd 20/03/07

Chase House Ltd 28/09/05

Chase House Ltd 29/06/04

Chase House Ltd 02/02/04

Similar services:

Claremont House

Chesham House

Argyll House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Firstlings

Dolphin Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Chase House Ltd House Lane Arlesey Bedfordshire SG15 6YA Lead Inspector Sally Snelson Unannounced Inspection 30th December 2005 11:55 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 Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chase House Ltd Address House Lane Arlesey Bedfordshire SG15 6YA 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) 01462 731276 01462 731276 Chase House Limited Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Physical registration, with number disability over 65 years of age (36) of places Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two service users under the age of 65 years of age may be admitted to the home from time to time in the category of PD or DE. No one under the age of 65 years can be admitted to the home when there are already 2 service users under the age of 65 years accommodated. 28th September 2005 Date of last inspection Brief Description of the Service: Chase House is a two-storey Victorian building, with an extension built on to it in the style and character of the original building. The home provides accommodation for thirty-six people in single and shared bedrooms. The majority of the individual bedrooms are situated on the first floor. Acess to the first floor is via shaft lifts or stair cases. The lounges and dining facilities are on the ground floor. There is a large conservatory overlooking extensive landscaped gardens that have a view of a very attractive water feature and the Bedfordshire countryside. The home is situated within easy walking distance of Arlesey Village, which is on the main bus route from Hitchin to Bedford. The towns of Letchworth Garden City and Hitchin are three and four miles away respectively. The home offers nursing and social care to older people including those with a physical disablement or dementia. The home offers a wide range of activities and excursions, including holidays. Staff help service users organise these breaks and accompany them as necessary. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of Chase House was unannounced and took place on 30th December 2005. It was the second inspection of the year and followed an inspection where the majority of the core standards had been assessed and only one requirement had been made. Therefore this inspection report should be read in conjunction with the report from the previous inspection dated 28th September 2005. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the services provided. During the inspection the care and the associated documentation for one service user was ‘case tracked’. A number of other service users were spoken to and aspects of their care assessed. Some of the staff on duty contributed to the inspection. The inspector would like to thank the staff and the service users for the time they gave to this inspection. What the service does well: The home offers care for service users, many who have a diagnosis of dementia, in a homely, relaxed atmosphere. The home is comfortably decorated and service users are encouraged to move around the home and join in activities at will. On the day of the inspection there was a coal fire in the lounge, which made a focal point for many of the service users to look at and to talk about. Many of the service users spoken to had enjoyed the Christmas celebrations. One of the service users said “They made it nice for us, we all had a good time”. The home benefits from a fairly consistent staff team that have worked at Chase House for some years. Staff know many of the service users because they come from, or have contacts, with the village of Arlesey and the surrounding area. During the inspection it was apparent that service users were consulted about their routines and could make choices. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 7 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 Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5,6. There was poor documentation to support the pre-admission assessments that were carried out before a service user was admitted to Chase House. EVIDENCE: The inspector was shown a completed document, based on the activities of daily living, which the nurse in charge confirmed was the pre-admission assessment tool. This document would benefit from being labelled as a preadmission assessment form to ensure that it was easily recognisable in the file. She confirmed that she would move all the documentation into one file. It was noted that the date of the assessment for the service user whose care was being tracked suggested that the assessment had taken place after admission. Further investigation of other service users notes indicated that this was not unique to the service user being tracked. In one case the pre-admission assessment had been reviewed. The nurse in charge suggested that the confusion was due to some of the qualified staff updating and replacing documentation to improve care standards and practices. She was clear that a pre-admission assessment should be a stand-alone document that was the proof that the home could meet the assessed needs of the service user at the Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 9 point of admission. If the assessed needs changed the reviewing should be to the care plans drawn up as a result of the pre-admission assessment and not to the original document. After the inspection the manager confirmed that the pre-admission assessment tools were stored elsewhere and the documentation looked was not that completed at the pre-admission assessment. A service user confirmed that she had been visited prior to being admitted to Chase House and that there was an opportunity for her or a relative, on her behalf, to visit the home as part of the decision making process. Chase House offered respite but not intermediate care. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Care plans were comprehensive and confirmed that staff were aware of the assessed needs of the service users. EVIDENCE: The care plans inspected had been well written, reviewed regularly and appeared to cover all the areas of identified care needs for the service user. It was noted that service users health needs were kept under review. For example, service users were regularly screened for the risk of developing pressure areas and weighed monthly as part of nutritional screening. Care plans confirmed that service users had sight and hearing tests as necessary and that the chiropodist visited regularly. On the day of the inspection the GP had visited during the morning. Staff confirmed that service users could ask to see the GP and that he always made time for them. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 11 Medication records showed that medication was correctly ordered, stored and administered. The trained staff confirmed that they audited the medication charts at every medication round and if there was in gap where a signature should have been they would contact the colleague who had been responsible for the last medication round for clarification. This practise is only acceptable if it is carried out within a reasonable timescale when the member of staff could be expected to remember whether a service user had taken or refused the medication. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff were aware of how to protect service users from abuse but were not clear about reporting abuse; this could put service users at risk. EVIDENCE: On the day of the inspection staff were unable to locate the home’s policy for the protection of Vulnerable Adults (POVA). If there was a current policy it was not kept with the other policies for the home. The home should have a policy that reflects that of the Local Authority and includes the Department of Health guidance ‘No secrets’. Following the inspection the manager provided this information and a copy of her certificate as a trainer for the protection of vulnerable adults training. The nurse in charge could speak concisely about the various forms of adult abuse and how they could be recognised. She confirmed that she and the manager did regular teaching sessions for staff, which included adult abuse and how to prevent it. However there was little evidence that the trained staff knew the processes for reporting any cases of suspected abuse and the importance of taking instruction from the lead agency. The previous inspection had confirmed that staff were recruited in an appropriate manner that protected service users from being cared for by staff that had been considered unsuitable to work with vulnerable adults in the past. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 21,24 The home was comfortable, well decorated and met the needs of the service users. Service users had the opportunity to personalise their bedrooms with ornaments and items of furniture from home. EVIDENCE: The inspector looked at the bedroom of the service user whose care was being tracked. His bedroom had items of furniture from his own home. The positioning of some of these pieces of furniture meant that it was not possible to include all the furniture listed in standard 24.2 of the National Minimum Standards in his room. Staff confirmed that the missing items could be made available if requested, but because he was happy with the layout of his room they had been omitted. It was noted that there was no documented evidence to support this statement. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 15 The bathrooms were clean and tidy. Staff confirmed that many of the service users preferred the bathing facility on the ground floor and would opt to use this one rather than one nearer their bedroom. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35,38 Service users were safeguarded as any small amounts of money, held on their behalf was kept securely. EVIDENCE: Staff and service users spoke of a happy atmosphere in the home. More than one member of staff spoke of the good leadership and support provided to them by the management. Service users personal monies were checked. It was apparent that small amounts of monies could be held at the home on their behalf. These monies were appropriately stored and all the transactions documented. During the inspection the maintenance person was carrying out the routine health and safety checks on the home. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X X 3 X X 3 X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X 3 X X 3 Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? NO 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 OP3 Regulation 14(1) Requirement There must be documented evidence in the service users file that a pre-admission assessment has taken place prior to admission. All staff must be trained in the Protection of Vulnerable Adults. This training should be part of the staffs induction programme and should be regularly updated. Key staff must attend multiagency training. Timescale for action 01/03/06 2 OP18 13 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000015034.V267357.R01.S.doc Version 5.0 Page 20 Chase House Ltd 1 Standard OP18 All staff must be aware of how to report a suspected case of abuse. Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 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 Chase House Ltd DS0000015034.V267357.R01.S.doc Version 5.0 Page 22 - 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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