Inspection on 20/06/05 for Chasedale

This inspection was carried out on 20th June 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 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 02/02/06

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 20 June 2005 09:30 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 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. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 Tamaris Healthcare (England) Ltd 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) Mrs C Guy CRH 60 Category(ies) of DE(E) Dementia - over 65 (50) registration, with number OP Old age (10) of places Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 6th January 2005 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). Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over a period of 5 hours on one day by the inspector, who has visited the home on a number of previous occasions. The manager was on duty which allowed the examination of records which were being stored securely in line with the homes policy on confidentiality. Eight residents were spoken to during the visit and four relatives and the inspector also spoke to seven of the staff the in process of the inspection visits. During the inspection the records examined included, five care plans and medication records, the training records, the fire log as well as complaints and accident records. The inspector also viewed three staff files including the process for their recruitment and selection. What the service does well: The residents spoken to during the visit were positive about the care being delivered and those residents who were able to express their opinions were complementary about the staff and the way they are supported. An example of resident comments are “the staff are good and will do anything asked”. The food being served during the visit was well received by the residents of whom seven said that they enjoyed it for example “Food is really nice”. The Manager and staff have regular, meetings with the relatives of the care home residents, as well as day to day contact with them regarding general issues. All negative comments are recorded so that the Manager can analyse them for quality assurance purposes. The home is clean and well decorated and was tidy on the day of the visit although it was not planned. The home is providing training opportunities for the staff which is well documented and planned, this allows the Manager to easily identify the programmed being delivered and identify any gaps or omissions. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 6 There is a service users guide in place, which is given to new residents and their family containing information needed to make a judgement about moving into the home. There is the opportunity for those who wish to visit the home prior to admission to do so. 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 not issued the amended contract so that the homes can implement it. EVIDENCE: A copy of the service user guide was examined, and included the name and details of the manager and the staff, in addition to the general information about the services provided within the home. Two relatives spoken to had seen this pack and it is made available in the entrance to the home. 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. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 9 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. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 10 Individual care planning is undertaken and the care is being delivered in line with these plans. The residents are having their needs met and are being given their medication in a safe way according the prescriptions of their General Practitioner. The staff are aware of the need to maintain residents privacy are doing so as part of their delivery of care, including the use of a door handle hanging notice explaining not the enter the bedroom as personal care was being provided. However, some door locks were not operational and therefore could not be used to maintain privacy. EVIDENCE: Each resident has an individual plan of care, which is based on the admission assessment and is then added to during the placement. Six 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 Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 11 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 satisfactory with evaluations being dated and signed. The home has policies and procedures in place to ensure the safe administration of medicines. The treatment room was clean and well organised. There was no over stocking of medication and minimum controlled drugs in use. A random check of the Medicine Administration Records and the Controlled Drugs found no discrepancies. The home has sight of the prescriptions and record all medicines received and disposed of with dates and signatures of staff and the pharmacist. The door locks on some of the bedrooms have had the mechanisms removed thus preventing them from being locked when staff are providing personal care or for reasons of maintaining personal privacy. It is acknowledged that the staff are using door handle privacy notices, however this does not replace the need for door locks. This may have occurred as a result of the home changing the use of the units for the client groups. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 standard(s) 15 The food being served is being prepared safely by knowledgeable staff and offers choice to the residents. The home offers the resident a balanced diet and there is sufficient quantity of both food and fluids to meet their needs. Staff are aware of the importance of a balanced diet and the way it is served. EVIDENCE: The kitchen was clean and well organised, the recording of food, fridge, and freezer temperatures were in place and completed appropriately. There was an ample supply of frozen, tinned, dried and fresh food available all of which was appropriately stored. The kitchen staff were aware of residents specialist needs including how to fortify foods for those who have poor appetites or those who have lost weight. The residents are offered a choice of three meals a day and residents on the day were seen eating heartily one asked said that the “food is really nice”. The meal being served was ample portion size, hot and well presented. Residents were offered assistance in a discreet manner. Residents were offered second helpings and alternatives to the main and dessert course were available. A variety of cold drinks were available throughout the meal and hot, cold drinks and biscuits were available throughout the day. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 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. The residents are protected by ensuring that the staff are given Protection of Vulnerable Adults training and whistle-blowing as well as reporting concerns to the Manager. 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 tow 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 interviewed 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. Written guidance is in place regarding the protection of vulnerable adults. Staff confirmed that they knew about the guidance and could identify the action they would take if they were made aware of or had any concerns regarding this issue. Staff are being given training on protection of vulnerable adults. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 standard(s) 19, 21, 22, 23, 24, 25, 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. However the wardrobes in the bedrooms were not secured to the walls, which presents a risk of toppling over if pulled. 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. 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. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 15 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. During the visit it was noted that not all of the wardrobes in the bedrooms were secured to the walls, which presents a risk of toppling over if pulled on severely and is the subject of Health and Safety Commission advice. This may have occurred as a result of the some residents changing bedrooms when the units were changed around and action must be taken to resolve this. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff were observed to follow infection control policies throughout the day. The light and emergency call cords were all clean and all emergency cords reached skirting level. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 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. The staff are recruited and selected using a system which ensures that they are able to care for the residents and have not been identified as posing a risk to their welfare through Criminal Record Bureau and the Protection of Vulnerable Adults List. 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. Three staff records were examined and were all complete including two references and a completed application form, the requirement to have a CRB and POVA check in place is applied to all of the staff in the home. The training records maintained by the Manager to allow her to plan for training was examined, it was very clearly maintained and offered a good system. There is evidence of a significant amount of training in both statutory and clinical areas of practice. All staff are receiving training in line with the company policy and statutory requirements. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35, 38 The Registered Manager, Mrs Guy, ensures that she has systems in place to make sure that the home is managed effectively taking into account the needs and wishes of the residents. She is continuing to consult the residents, staff and other interested parties to review the service provided and manage the staff in a way to improve care delivered. EVIDENCE: There is a policy for supervision, for care staff and the records to support the Managers confirmation that she attempts to ensure safe working practices for moving and handling, first aid, food hygiene and infection control were in place and, although the record needs to be brought up to date. The home has in place arrangements to ensure that persons working at the care home receive suitable training in fire prevention and by means of fire drills and training in the procedures to be followed in the case of fire. There is a system in place to review health and safety in the home involving the staff for which records are available. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 18 Records were examined of the staff meetings which take place regularly and the contents of these suggest that there a broad spectrum of relevant issues discussed. The Manager also facilitates meetings with the relatives and residents as appropriate. The personal records kept in the home of residents who are receiving assistance to manage their finances were examined and are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place, and there is a small float available for the staff to access. Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x 3 x x 3 Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? No - Standard 2 outstanding 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 OP2 Regulation 5 (1) (b) Requirement The updated statement of terms and conditions should be submitted to the National Care Standards Commission and be provided to new service users on moving into the home. Outstanding A risk assessment must be undertaken to identify the risk of the wardrobes not being fixed to the wall to reduce the potential of accident. Door locks must be repaired to ensure that staff are able to provide personal care and maintain resdient privacy. Timescale for action 01.08.05 2. OP19 13 (4) (a) 01.08.05 3. OP10 12 (4) (a) 01.09.05 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. Refer to Standard OP28 Good Practice Recommendations The Manager should continue with the training programme to ensure that a minimum of 50 of the care staff has achieved a level 2 NVQ award by end of 2005 Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 Chasedale B53-B03 S508 Chasedale V223218 200605 Stage 4.doc Version 1.30 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. 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!