Inspection on 10/08/05 for Chase Lodge Care Home Ltd

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chase Lodge Care Home Ltd 29/08/07

Chase Lodge Care Home Ltd 08/02/06

Chase Lodge Care Home Ltd 10/02/05

Chase Lodge Care Home Ltd 20/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Chase Lodge Care Home Ltd 4 Grove Park Road Weston Super Mare North Somerset BS23 2LN Lead Inspector Juanita Glass Announced 10 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chase Lodge Care Home Ltd Address 4 Grove Park, Weston Super Mare, North Somerset, BS23 2LN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01934 418463 Chase Lodge Care Home Ltd Mr Henry James Murray Bladon Care home with nursing 19 Category(ies) of Learning Disability (19) registration, with number Mental Disorder (19) of places Learning Disability - over 65 (19) Mental Disorder - over 65 Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accomodate up to 19 persons aged 30 years and over requiring personal care only. Date of last inspection 10 February, 2005 Brief Description of the Service: Chase Lodge is a care home catering for 19 people with mental health problems. The aim of the home is to provide a caring and supportive environment, which is relaxed and comfortable. The intention is for service users to function in a stress free atmosphere where demands put on them are minimal. The home does not set out to rehabilitate service users, however there are skills which they are encouraged to acquire leading to an enhancement in their life. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in the presence of the acting manager, Mr James Dillon, over seven hours. Most of the residents in the home were met and three members of staff spoken to. The extension to the home has been completed and the inspector was able to talk to all the residents living in the new rooms. Residents spoken to were happy with the care they received, and spoke highly of the support provided by the staff. Four requirements and one recommendation were made, and are discussed in the relevant parts of this report. Areas that still required redecoration were noted and discussed with the manager, however the progress had been held up due to an emphasis on completing the new building work. Six comment cards were received five from residents and one from a GP, they all praised the care and support residents received at Chase Lodge. What the service does well: What has improved since the last inspection? Structural changes and the building of an extension has provided more communal space and a larger a shared room for two residents. Staff are receiving training in the administration of medication, and a new pharmacy contract has been negotiated. The home has replaced the missing documentation covering adult protection. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 6 Staffing levels in the home are appropriate to meet the needs of the current resident group, the staff confirmed they no longer felt under pressure due to shortage of staff. 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 Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4 and 5 Prospective service users are provided with adequate information to make an informed choice about where to live. A full needs assessment is carried out prior to admission, and service users are given the chance to visit the home and stay for a trial period. Each service user has an individual written contract or statement of terms and conditions. EVIDENCE: The home has a very clear statement of purpose and service user guide which sets out the information required for residents to make an informed choice, there is no tariff of extra charges as the providers feel the fees should cover everything the residents need to lead a fulfilling life. The manager carries out a preadmission assessment and residents are not accepted into the home unless both the manager and the prospective resident feel that it can meet their needs fully. Resident records reviewed showed evidence of preadmission assessments, and all new residents are offered a trial period so that they can determine whether the home can meet their needs. Resident’s records all contained signed contracts of residence. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service users have clear assessed care plans however they dont evidence service user involvement. Service users are supported to make decisions about their lives. Service users are assisted to take risks however records dont evidence service user involvement. EVIDENCE: Six resident care plans were reviewed they were all very clear and concise; the plans are developed from an initial assessment and show evidence of regular review, they provide very clear directions for staff, and risk assessments identified that residents who may be at risk received guidance and assistance from staff to overcome that risk, these included tasks such as tea and coffee making, however it was difficult to prove that residents were involved in their care plans, risk assessments or reviews. One resident spoken to confirmed that he knew he had care plans and risk assessments, but said he didnt want to get involved. Residents records showed that they were encouraged to make their own decisions about life choices, residents were observed doing as they wished through the day, one resident spoken to the said that staff always helped him when he asked. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 17 The home enables service users to take part in age, peer and culturally appropriate activities and remain part of the local community. Residents decide what leisure activities to follow. The home provides a healthy nutritional diet. EVIDENCE: Staff actively assist service users to develop new skills and maintain independent living skills, residents records showed that they take part in the local community going to church, clubs and the local library, some service users have placements at the Charlton centre. An activities diary is kept and activities that are followed are agreed with the residents. At a recent residents meeting they decided to go to Bristol Zoo. Residents spoken to said that there was always plenty for them to do, one service user talked about the poems he writes and that the last one was published. Another service user spoke of the help he had had setting up his music system in his room. The inspector joined the residents for lunch which was an unhurried affair, the menu does not show a choice, however residents make requests during the Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 11 morning and these are accommodated when possible, the meal served was both wholesome, nutritional and appetising. Residents spoken to said that they always got a decent lunch and could request snacks throughout the day. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, in 19 and 20 Service users receive personal support in a way they would prefer their physical and emotional health needs are met. Policies and procedures for self-medication are in place. Storage and administration of medication meets current requirements. EVIDENCE: The home does not provide nursing care, however staff were observed to recognise residents needs for dignity and privacy, however the one shared room did not have appropriate screening, this is discussed further under the relevant standard. Residents spoken to said that staff are always nice and polite and understood when they wanted to retire to their rooms alone. Records reviewed showed that the home enables residents to access health care services, which included opticians, chiropodist, dentist and the community psychiatric nurse. It was also evident that the home enabled residents to attend outpatients’ clinics and assist them to stop smoking this demonstrates good practice. The receipt, storage and administration of medication was discussed with the manager, the home is currently taking up a new pharmacy contract so progress in this area will be looked at, at the next inspection. All staff administering medication have received training, and are continuing with the distance training course which provides more in depth knowledge. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 13 Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users views and opinions are listened to and acted on. The homes recruitment procedure does not protect service users from harm. EVIDENCE: Resident’s views and opinions are regularly sort at resident meetings. Residents spoken to said that they felt their opinions were taken into account and that they could approach any member of staff with a concern or complaint, minutes from resident meetings supported this. The home has replaced the Adult Protection Policy and Procedure for North Somerset, which was missing at the last inspection. Staff have clear guidelines in place for the protection of vulnerable adults, however it is recommended that staff attend formal training in the policies and procedures for North Somerset. Whilst checking staff records it was noted that new staff had been employed without a POVA 1st confirmation, this is discussed further under the relevant section of this report. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 28 and 30 Chase Lodge provides a homely and safe environment, with bedrooms and communal areas that suit the service users needs. The home is clean and hygienic, however some redecoration is needed. EVIDENCE: Following the recent programme of building works, residents have access to adequate and well furnished communal space and new bedrooms, two residents who have shared a smaller room moved into a larger new bedroom, and said they were very happy with the new space provided. It was noted however that this shared room had not been fitted with screening between beds to provide privacy; this was discussed with the owner who agreed to provide screening with immediate effect. Residents spoken to were happy with their rooms one resident did state that he was waiting for his room to be redecorated as it needed doing badly, this was discussed at the time with the manager who agreed it had been mentioned and was being planned. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 16 An area of damp in the hall still needs attention, however it was explained that the redecoration programme had been put on hold whilst they had concentrated on completing the building work and would be looked at next. The home was clean and tidy and staff were observed working in a way that showed an awareness of infection control issues. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, and 36 All staff have clear job descriptions, and adequate numbers of staff are in the home to meet service users needs. The homes recruitment practices do not follow requirements and do not protect service users. All staff receive support and supervision. EVIDENCE: Staff records examined contained very clear job descriptions in which their roles and responsibilities were clearly outlined. Staff spoken to said they were aware of their roles and responsibilities within the home which can be discussed at supervision or during staff meetings. The records for newly appointed staff were examined and did not contain POVA 1st confirmation, they also showed that staff had been employed before the full Criminal Records Bureau check had been obtained. A POVA 1st confirmation must be received before staff can commence employment they must then work supervised until the full CRB is received. Supervision records were seen for all staff and those spoken to confirmed that they received appropriate supervision which identified areas of training and development. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40 and 42 The home is well run with and the manager and staff are open and approachable. The homes policies and procedures safeguard service users with the exception of recruitment practices. The health and safety within the home does not meet current standards. EVIDENCE: The management ethos in the home is both open and approachable; staff and residents said that they could talk to the manager and owners at any time and about anything a friendly a relaxed rapport was observed throughout the inspection. The acting manager is commencing the Registered managers Award this September and has started the Registration process with the CSCI. The homes policies and procedures safeguard service users and give clear guidance to staff however as previously discussed the homes recruitment practice needs to be revised. Health and Safety within the home in general is adequate with six monthly risk assessments of the property recorded, and appropriate training of staff. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 19 However on examination of the fire log it was noted that a full fire risk assessment of the home needed to be carried out identifying areas of risk and residents who may smoke in their rooms, as well as escape routes and fire points. Staff have received training in Fire procedures and regular fire drills are carried out which also involves the residents. The appropriate fire alarm and equipment checks are also carried out. All staff handling food have food hygiene certificates and food was appropriately stored in the kitchen, which was clean and tidy. There was not a record of hot water temperatures available and it is recommended that the manager checks the temperature of the hot water and maintains a record to ensure resident safety. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chase Lodge Care Home Ltd Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x 2 x D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 21 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. 2. 3. 4. Standard YA 6 YA 18 YA 25 YA 34 YA 42 Regulation 15 16 (2) 19 23 (4) Requirement All care plans must show evidence of involvement Screening must be provided in the shared room New staff must be subject to robust recruitment proceedures including CRB/ PoVA first check The manager must complete a fire risk assessment of the home Timescale for action By 10/08/05 By 10/09/05 From 10/07/05 By 10/09/05 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. 2. Refer to Standard YA 42 YA 23 Good Practice Recommendations Hot water temperatures need to be checked and a record kept Staff need to attend training in the North Somerset Policies and Procedures for Adult Protection. Chase Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 Lodge Care Home Ltd D53 - D02 S46197 Chase Lodge V232120 100805 Stage 4.doc Version 1.40 Page 23 - 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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