Inspection on 02/02/06 for Chasedale

This inspection was carried out on 2nd February 2006.

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 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

Chasedale 10/02/10

Chasedale 21/01/10

Chasedale 27/10/09

Chasedale 28/01/09

Chasedale 22/04/08

Chasedale 29/10/07

Chasedale 02/11/06

Chasedale 20/06/05

Chasedale 06/01/05

Chasedale 11/08/04

Chasedale 09/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Chasedale Tynedale Drive Cowpen Estate Blyth Northumberland NE24 4LH Lead Inspector Suzanne McKean Unannounced Inspection 2nd February 2006 09:30 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 DS0000000508.V255897.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. DS0000000508.V255897.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chasedale Address Tynedale Drive Cowpen Estate Blyth Northumberland NE24 4LH 01670 - 365997 01670 - 365722 chasedale@fshc.co.uk 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) Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care) Care Home 60 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (10) of places DS0000000508.V255897.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user is under 65 years of age. The Commission for Social Care Inspection must be notified immediately should this service user leave the home so that this condition can be removed. 20th June 2005 Date of last inspection Brief Description of the Service: Chasedale Nursing Home is a two storey, purpose built facility of traditional brick build and tiled construction. It is situated on the edge of a large residential estate approximately two miles from the centre of the town of Blyth and the home is well served by public transport. The home has a car park to the front of the home from which there is level access to the main entrance. There are grassed sitting areas, which are accessible to, and for the use of, residents and visitors. The home is registered to provide care to 60 persons 10 of which are the category of old age requiring nursing care and the remaining 46 under the category of dementia care (nursing). DS0000000508.V255897.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was over a period of 4 hours. This is the second unannounced inspection the home has had this year and the core standards have been examined over the inspections. Both reports should therefore be looked at for the full picture. During the inspection nine residents, two relatives and two of the staff were spoken to. The records examined included, four care plans and medication records, and the records for complaints and accidents. There were three requirements identified during the last inspection and one recommendation, all of which had been met by this inspection. During this inspection one requirement was identified and one recommendation. What the service does well: What has improved since the last inspection? The three requirements made at the last inspection have been met. The home now has locks on all of the bedroom doors, the wardrobes are securely fixed to the wall. Four Seasons now has a contract in place with has been issued to the residents and will be used for new residents as they are admitted. DS0000000508.V255897.R01.S.doc Version 5.0 Page 6 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. DS0000000508.V255897.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 DS0000000508.V255897.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): 2, 3 The assessment undertaken prior to admission is detailed and the staff are being given training to meet the needs of the residents in the home. The company has now issued the amended contract and these have been issued to the residents. EVIDENCE: Five care plans were examined and each has comprehensive pre-admission assessments, which were undertaken by the Manager or the senior staff in the home. The residents also have a care management assessment, which is provided, to the home on admission and from these documents an individual care plan is produced. The home is not registered for, and therefore does not provide, intermediate care. DS0000000508.V255897.R01.S.doc Version 5.0 Page 9 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, 10 Individual care planning is undertaken and the care is being delivered in line with these plans. The staff are aware of the need to maintain residents privacy are doing so as part of their delivery of care. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment and is then added to during the placement. Four care plans were examined and they were completed to a good standard. There was evidence that relevant risk assessments are available for the prevention of falls, nutrition, wound care, moving and assisting, continence promotion and mental health status. The plans showed that they are regularly reviewed and updated and that reviews are regularly held with residents and their representatives. The care plans showed that the residents have access to all NHS services and facilities. There was a good range of pressure relieving mattresses in use for the prevention of pressure sores. The recording of the nursing action taken for wound care was detailed with evaluations being dated and signed. DS0000000508.V255897.R01.S.doc Version 5.0 Page 10 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): 12, 13, 14 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their cultural, social, religious and recreational interests and needs. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. There is a social programme in place however this must be developed further with assessment and documentation in place to ensure it is appropriate for each individual resident. EVIDENCE: It was noted during the visit that a large proportion of the residents in the home although they were not able to have a conversation with the inspector were very “happy” in that they were smiling with the staff or were laughing together. Some of the residents were moving around the home and were being encouraged to so even when they were at some risk of falling, this is to be commended as the staff have looked at the risk and taken steps to minimise the risk without restricting the resident choice. The home does not currently have an activities co-ordinator although the manager is actively recruiting for a replacement. Staff were seen on the day to be involved in activities with the residents on a one to one basis mainly DS0000000508.V255897.R01.S.doc Version 5.0 Page 11 because of the time of the visit (morning) this included sitting talking and doing hand care. There was information displayed on the walls identifying the organised activities that go on including bingo, dominoes and the visits of entertainers. Each resident care plan examined had a need identified and a plan section regarding the resident social care needs. However these were not detailed and specific enough to identify the individual choices and preferences. The “Detailed Social Care Assessments” which is an tool provided and used within the Four Seasons organisation were present in two of the care plans but not completed and the other two did not contain one. The care plans in two specifically identified the need to complete this document. Two visiting relates and the staff in the home confirmed on discussion that residents are encouraged to take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. Residents confirmed that they are able to make choices about how they spend their day where they are able to do so verbally and if not are supported to move around the home freely. The residents’ bedrooms were personalised reflecting individual choices and preferences and two residents asked about their bedrooms said they were happy with the decoration. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives are given information within the residents’ guide about visiting arrangements. DS0000000508.V255897.R01.S.doc Version 5.0 Page 12 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): 16, 18 The home ensures that the residents and relatives are made aware of the complaints policy and that it is available in a variety of places. There is a system for managing and dealing with complaints, which makes it possible for them to be investigated and action taken to address any issues identified. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance as well as being displayed in the home. The records of the complaints made to the home was examined, there has been six complaints recorded and the records of these were detailed including the response to the complainants and the action taken in response to the issues raised. Two of the residents who were spoken to during the visit who were able to express their views were asked about the way in which they would have any problems dealt with, each were able to identify the way this would be done. Three relatives who was visiting the home was aware of the complaints procedure but had not needed to use it. The home has been subject to two Protection of Vulnerable Adult investigations since the last inspection both of which were reported by the Manager. These were resolved by the home with the support of the Social Services department and showed the Manager, Mrs Gibbon’s determination to ensure the safety of the residents in her care. DS0000000508.V255897.R01.S.doc Version 5.0 Page 13 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): 19, 26 The home is well decorated and is safe for the residents to live in. It is being maintained in a satisfactory way and there is a programme in place to ensure that the redecoration and maintenance is undertaken. The bedrooms are all single occupancy and are decorated and equipped in a homely and personalised way. There are suitable toilets and bathrooms, which are well equipped and nicely decorated. The necessary specialist equipment is provided in the home and when required appropriate advisors are brought in to offer advice and assess residents needs e.g. Physiotherapy. DS0000000508.V255897.R01.S.doc Version 5.0 Page 14 EVIDENCE: A tour of the home was conducted both with staff and alone to assess the general condition of the home. It is tidy and organised in such a way to make sure that the residents are able to use the home safely. It is purpose built and is well maintained and there is evidence of some refurbishment and redecoration-taking place as necessary. The home is clean and was odour free on the day, although there was a domestic less than on duty than usually due to sickness. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. DS0000000508.V255897.R01.S.doc Version 5.0 Page 15 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): The home is staffed with appropriate numbers of staff and there are qualified nurses on duty in sufficient numbers to meet the needs of the residents. EVIDENCE: Staffing rotas showed that the Manager is ensuring that enough staff are on duty to meet the staffing levels set down prior to the change to the CSCI without reduction. It was noted that when sickness and staff holidays occur these occasions are usually covered by home staff. However when this is not possible agency staff are being used, late reporting does occasionally result in fewer staff being on duty for short periods. DS0000000508.V255897.R01.S.doc Version 5.0 Page 16 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): 31 There has been a change in the Manager since the last inspector. Mrs Susan Gibbon is currently undertaking the fit person process to be registered with the Commission for Social Care Inspection. EVIDENCE: Mrs Susan Gibbon is now the Manager of the home, she is currently undertaking the fit person process necessary for her to be registered with the Commission for Social Care Inspection. Mrs Gibbon demonstrated a commitment to maintaining the safety of the residents and to provide care in line with the national minimum standards. There have been a number of issues raised since she has become the Manager including two Protection of Vulnerable Adults referrals. Mrs Gibbon has demonstrated a willingness to deal with these in a rigorous and timely way. These were particularly difficult events, which were dealt with very effectively. DS0000000508.V255897.R01.S.doc Version 5.0 Page 17 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X X DS0000000508.V255897.R01.S.doc Version 5.0 Page 18 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 OP12 Regulation 16 (2) (m) Requirement The social programme must be developed further to ensure that it takes into account the needs and wishes of the service users and is recorded in detail. Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP31 Good Practice Recommendations The manager Mrs Gibbon should continue with her proposal to be registered as the manager with the CSCI. DS0000000508.V255897.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000508.V255897.R01.S.doc Version 5.0 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!