Inspection on 09/12/08 for Chasewood

This inspection was carried out on 9th December 2008.

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

Chasewood 02/06/09

Chasewood 08/05/08

Chasewood 08/11/07

Chasewood 15/06/07

Chasewood 07/12/06

Chasewood 11/05/06

Chasewood 01/02/06

Chasewood 05/05/05

Chasewood 06/01/05

Chasewood 18/06/04

Similar services:

Maple Lodge

Heathlands

Breme

Ravenhurst

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Chasewood 39 School Lane Exhall Coventry West Midlands CV7 9GE Lead Inspector Julie McGarry Unannounced Inspection 9th December 2008 09:40a 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 DS0000004216.V373470.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000004216.V373470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chasewood Address 39 School Lane Exhall Coventry West Midlands CV7 9GE 02476 738211 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) Chasewood Care Ltd Mrs Catherine Tranter Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places DS0000004216.V373470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th May 2008 Brief Description of the Service: Chasewood is a converted, detached property, providing accommodation on two floors. The home is set back from the road and to the front of the home there is parking space for about six cars. The home is registered to provide care for 22 elderly people with a dementia. The ground floor of the home provides accommodation for fourteen people. There is a large open-plan communal area at the centre of the ground floor, and leading off from this area are three wings providing bedrooms, a kitchen, laundry and the managers office. There is a further lounge with a conservatory leading into the garden. Ten single bedrooms are provided for people at ground floor level, and two shared rooms. There is a shaft lift to the first floor, as well as the stairs, where accommodation is provided for eight people. Facilities provided on this floor are a lounge, dining room (with a kitchenette), and six bedrooms, two of which are shared rooms. There are two separate lavatories at this level, a bathroom and a shower room. On the ground floor French windows lead onto the rear garden, and the home has a small patio area to the rear of the property. Information about the home is available in an information booklet provided in the entrance of the home. The manager has advised on 26th February 2009 that the current fees for a place in the home is £416 per week. Other additional charges include the hairdresser, chiropody, personal toiletries, newspapers and magazines. DS0000004216.V373470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a zero star; this means that people using the service receive poor outcomes. This was a key unannounced inspection visit. This is the most thorough type of inspection when we look at all aspects of the service. We concentrated on how well the service performs against the outcomes for the key national minimum standards and how the people living there experience the service. Two inspectors carried out this Key inspection. Before the inspection we looked at all the information we have about this service such as information about concerns, complaints or allegations; incidents; previous inspections and reports. Information about the service was also received in the form of an annual quality audit assessment (AQAA). This gives us information about the home and its development and was completed by a manager in the organisation. Since the last Key inspection carried out in May 2008, two random inspections have been undertaken one in June 2008, and one in September 2008. These inspections were carried out to determine if specific requirements from the Key inspection had been met and within required timescales. Not all requirements issued at the Key inspection were met at the first random inspection, and a statutory notice was issued to the home. At the inspection in September 2008, we found that the home had met the requirements of the statutory notice, however one requirement remained outstanding from the previous inspection. At this Key inspection we used a range of methods to gather evidence about how well the service meets the needs of people who use it. Some time was spent sitting with residents in the lounge watching to see how residents were treated and looked after. These observations were used alongside other information collected to find out about the care they get from staff. We also looked at the environment and facilities provided and checked records such as care plans and risk assessments. Four people using the service were identified for case tracking. This is a way of inspecting that helps us to look at services from the point of view some of the people who use them. We track peoples care to see whether the service meets their individual needs. Our assessment of the quality of the service is based on all this information plus our own observations during our visit. DS0000004216.V373470.R01.S.doc Version 5.2 Page 6 Throughout this report, the Commission for Social Care Inspection will be referred to as us or we. At the end of the visit we discussed our preliminary findings with the provider and a member of staff was present. The improvements found to have been made in the last random inspection in September 2008, have not been fully sustained. What the service does well: Staff were seen to speak to the people who live at the home in a respectful way. Care plans to meet daily needs have improved. Relatives and friends were seen coming and going from the home and appeared comfortable and welcomed. People receive visits from representatives from local churches to meet their spiritual needs. The environment is homely and comfortable there are sufficient bathrooms and toilets and the home meets the needs of people. Rooms are personalised giving a feel of individuality and ownership. There are sufficient staff available to meet the needs of the residents. Comments from people who live here include : ‘No complaints what so ever, happy, content here, though not literally, this is my home’. ‘No problems with cleanliness’ ‘I have recently been in bed unwell, staff visit a lot’ ‘Best of attention here’ Comments from visitors to the home include: ‘Lovely care’ ‘Can’t fault them’ (referring to the staff) ‘Always plenty of staff about’ DS0000004216.V373470.R01.S.doc Version 5.2 Page 7 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. DS0000004216.V373470.R01.S.doc Version 5.2 Page 8 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000004216.V373470.R01.S.doc Version 5.2 Page 9 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 DS0000004216.V373470.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3. Quality in this outcome area is adequate. Prospective residents and their representatives have the information needed to choose a home. Prospective residents have their needs assessed prior to moving in. People are not provided with a written contract. The home does not offer intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000004216.V373470.R01.S.doc Version 5.2 Page 11 The case files of two people recently admitted to the home, plus two others identified for case tracking were examined to assess the pre-admission process. Assessments provide some details of their health and personal care needs, greater detail is needed to ensure that the home is confident that they can meet people’s needs before they move in. For example, one person’s record states ‘can become quite aggressive’, there is no further detail about what this means for that individual, what it will mean for staff or the impact upon other people who live there. There is no information in the pre-admission records to show that this person was invited to visit the home before moving in, or that they or their representatives were able to take up any opportunities to visit the home before the person moved there. There is information on both people’s files detailing the individual’s perspectives about moving to live there and that of their relatives perspectives. A Social Services report and care plan is on one person’s file, however this was received after the person moved to live at the home. Another person moved to the home with a ‘chronic foot problem’. There are no further details to inform staff about this need and how the home will be able to meet this need. A care plan is in place to guide staff on the care that needs to be provided, however there are no entries in the daily records to show that this care is being carried out. The owner informs us that people do not have individual contracts with the home, the home has contracts with the local authority in respect to people’s stay there. Surveys returned by two people who live here state that they have not received a contract. There have been no changes to the ‘Information pack’ since the last inspection. The fees for living there were not included in the ‘Information pack’. DS0000004216.V373470.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Each resident has a plan of care, but there is an absence of detailed recording. Residents have access to healthcare services that meet their assessed needs. The medication system is monitored and improvements have been made to reduce mistakes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal profiles and care records of four residents identified for case tracking were examined. Shortfalls in people’s care plans and risk assessments were identified. DS0000004216.V373470.R01.S.doc Version 5.2 Page 13 One person’s care plan states that they need a lot of encouragement to eat their meals and take fluids. Documentation in medical records noted a weight loss of nine kilos for this person and recommend a referral to the GP for dietician input, there is no evidence that a referral was made. Instruction in the records state that staff should monitor food intake, there is no written evidence to show that this is being done. Records show that there are instructions from the GP for this person to be weighed more frequently, again there is no evidence that this was done. The home did not review and update the care plan when weight loss became a concern. A Risk assessment for a further individual who at times did not eat was available, care plans stating what staff were to do in this event were not available. There was no separate food intake chart, food eaten was inconsistently recorded in the daily reports, and did not state quantity or quality of food intake. Another person’s care plan states that they have swallowing difficulties, and the care management review from social services tells us that this person requires ‘hard food to be liquidised’. The care plan did not contain this information clearly. Evidence from observations and discussion with staff told us that this person is receiving an appropriate diet. This person’s care plans also states ‘not swallowing tablets, XX will keep tablet in mouth and pretend to swallow. Staff have found tablets in the drawer in their room, staff to make sure XX swallows his medication’ it is not clear in the records how staff do this and where it is then recorded, which may impact on the evaluation of the prescribed care. The care plan also stated that, ‘Staff to monitor and get in touch with GP for liquid medication’, as there is no clear monitoring process it was difficult to determine if this person required liquid medication. All medicines at the time of this visit were in tablet format. Two people’s risk assessment plans show that they present with ‘physical and verbal aggression’. There are no care plans to tell staff how to deal with this in a consistent manner to ensure the safety of these two people and those around them. Assessment of the reasons for this behaviour is not evident and there is no information of actions that staff can take to prevent escalation of physical and verbal aggression. Residents have access to a range to their GP, chiropodist and optician on a regular basis or when required, requests for unplanned specialist support is not consistently requested such as the dietician. People spoken to confirmed that they see their GP, Chiropodist and Optician as needed. DS0000004216.V373470.R01.S.doc Version 5.2 Page 14 We looked at the systems for management of medicines. Six residents medication was looked at together with the medicine charts and care plans. Two staff trained in medication administration were spoken with. The medication was stored in two medication trolleys and appropriately attached to a secure wall. The controlled drugs cabinet is kept in the office. There were no records of temperatures being maintained to show that medication is being stored at appropriate temperatures. Temperatures must not exceed 25C. Above this temperature the stability of most medication is compromised. From the six people’s medication looked at, the medication for four people was correct. The home checks all prescriptions before they go to the chemist and check all medication arriving into the home, a copy of the prescription is kept with the medication administration sheets as a reference. The home informs us that audits are being carried out to check that medication is being monitored, stored and administered correctly, however we saw no evidence for this and the person who carries out this role was not available to be spoken with. When checking the medication two discrepancies were found. One Paracetamol tablet was missing, and records on the Medication administration sheet did not clearly indicate if this person was having one or two Paracetamol tablets each time they were administered. Three aspirin were missing on another person’s records. When we spoke to staff they could not account for the missing tablets. The care plans lacked details of all the medication the residents were prescribed. It could not be demonstrated exactly why some residents had been prescribed some medicines. Without such information staff would not be able to fully support the clinical needs of the residents they look after. One person has been prescribed a GT spray (a spray used in the mouth to alleviate heart pain) to be used when required. There are no protocols kept with this spray to inform staff when the spray needs to be used, how it should be administered and what should be recorded. The controlled drugs cabinet had two envelopes with the first name of one person written on the front, and instructions ‘tonight plus bedtime tablets’. Instructions on the second envelope stated ‘tomorrow morning’. There were no instructions as to what the medications were or why they were stored in the controlled drugs cabinet cupboard. DS0000004216.V373470.R01.S.doc Version 5.2 Page 15 Minutes from a recent staff meetings tells us issues relating to medication have been recognised and addressed appropriately. People living in the home were observed to be treated with respect and their dignity maintained for example, personal care was provided in private and residents were spoken to respectfully. During observation of working practice, it was evident that staff are knowledgeable about the likes and dislikes of people living in the home and were kind caring and attentive towards them. Residents and visitors spoken with said they felt their privacy and dignity was respected. We received two surveys from people who live at this home, comments in the surveys included: ‘Staff always helpful, kind and thoughtful, happy’. ‘Recently I became unwell and received visits from the carers’. DS0000004216.V373470.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. Activities are available, but need to be developed to reflect the individual needs and daily living skills of the people who live at the home. The standard of food is good but people living at the home could be more involved in planning the menu. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The range and availability of activities at the home is limited. Since the last inspection, the home has employed an activities person to work one day a week. On the day of the inspection we observed the activities person interact with people in the lounge. This consisted of ball games, chair exercises and chatting to people as they relaxed. Throughout the inspection, the home played music in the main lounge area and this appeared to please people who listened to this. One lady was observed to join in with the singing, and when DS0000004216.V373470.R01.S.doc Version 5.2 Page 17 we spoke to her, she confirmed that she liked the music that was being played. In the afternoon, we observed the activities person spending time with two people upstairs playing a board game. We observed good interactions between the activities person and people who live there. When we spoke with the activity person, they confirmed that they worked at the home one day a week. There are no formal activities arranged for other days, however the activities person feels that there is a good budget available for him to purchase games and craft items. People’s daily records do not record opportunities they are offered or particulate that are meaning or stimulating for them. As recorded at the last inspection, ‘there continues to be very little information in the care plans that reflect people’s social needs. Where life history and past hobbies have been recorded there is no positive actions taken to follow these up’. This means people continue to lack stimulation and are not being given the opportunity to continue with past activities reducing their quality of life. There is evidence that people are able to maintain links with their families and friends and attend church services at the home to enable people to practise their faith. The home has no restrictions on visiting. Relatives and friends were seen coming and going from the home and appeared comfortable and welcomed. The inspector spoke to one relative who confirmed she could visit when she wanted and was always made welcome. Another person spent their time at the dining table reading the newspaper. They were joined by a visitor in the afternoon, who told us that they felt that their friend was receiving ‘good care’ at the home. Records for one person states that they ‘will smoke in corridors and room, and put cigarettes out in the sink in the bedroom’. ‘Staff to take lighter off XX when going to their room’. Daily records state ‘having hourly cigarette’ however there is no care plan in place to reflect this arrangement. Records do not detail who made this decision and if this person is in agreement to this. One member of staff when asked about this arrangement, told us that if this person wanted more than one cigarette every hour, they would be told that they have to wait if they have already had a cigarette. Records should clearly detail why such arrangements are in place, who has made the decision, and if this person is in agreement to this. There have been no changes to the running or the kitchen since the last inspection. Menus are held in the kitchen for a four-week period. The cook said that food orders and the menus are done at the sister home Chasewood Lodge. Therefore people in the home are excluded involvement in planning menus. However, menus showed that the people who live there have a choice of meals through the day. The menu was varied and meals appeared DS0000004216.V373470.R01.S.doc Version 5.2 Page 18 nutritious. On the day of inspection, people were offered a choice of minted lamb or braising steak for lunch. On the day of the inspection, people who live at the home were supported to get up at different times through the morning. One person told us that they were given the option of having breakfast in their own room or the dining room. The cook informs us that people are offered the choice of a cooked breakfast each morning or cereals, tea, toasts etc. Kitchen staff have records to inform them of people diets. There are choices offered for each meal each day, with the addition of a pureed diet alternative when necessary. People living in the home appeared comfortable sitting in the different lounges or ‘pottering about’ and using all the spaces in the home. Residents interacted well with each other and staff. DS0000004216.V373470.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. There is a complaints procedure in place. Incidents of abuse are not followed up promptly and no record of action taken is maintained. The home needs to ensure more robust practices are in place to ensure staff respond appropriately to safeguard and protect people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints policy which is on display and people are encouraged to raise their concerns with the staff. Residents were observed to be familiar with the staff and appeared confident to make requests. It was evident that the attitude and response to complaints from staff and management has improved. People are responded to in an appropriate manner, and outcomes of any complaints are given in writing. One person spoken to was asked who they would complain to if they weren’t happy, they replied ‘I wouldn’t be here if I wasn’t happy’. Another person told us ‘I have no complaints, I am happy’. DS0000004216.V373470.R01.S.doc Version 5.2 Page 20 The home has an adult protection policy to give staff direction in how to respond to suspicion, allegations or incidences of abuse. Staff spoken showed some evidence of their understanding of the polices and procedures, and are aware that any incidents or allegations of abuse need to be reported to the person in charge. Three incidents of verbal and physical aggression had occurred in the weeks previous to this visit. Written information tells us that staff did not recognise that these incidents should have been reported to Warwickshire Safeguarding as stated in local policy. The home needs to ensure that incidents of abuse are followed up promptly and action taken is recorded. Three staff files were seen. None contained evidence that staff having received training in the Protection of Vulnerable Adults. Other records sampled did show certificates of this training. The home needs to ensure all staff have an understanding of how to apply the procedures in their work to ensure consistent knowledge and practice in the home. DS0000004216.V373470.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The environment is homely and meets the needs of people who live there. Infection control procedures in place safeguarding people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no changes to the home’s environment since the last inspection. People have a choice of two lounges, one upstairs and one downstairs to sit in. We observed people making use of both rooms, and saw that people were able to move freely between the rooms. DS0000004216.V373470.R01.S.doc Version 5.2 Page 22 People continue to be encouraged to bring personal items in the home to make them individual and give the people using them a sense of ownership. People’s rooms were clean and tidy and displayed their person possessions. Most people have single rooms, however one shared room was seen at the inspection. This was spacious and had room to accommodate the hoist needed to meet one person’s needs. There is a curtain in place to help maintain both people’s privacy and dignity, however this needs to be extended to ensure complete privacy when personal care is being provided. There was an offensive odour in one person’s room. The owner informs us that he is aware of this and staff have been taking steps to address this. The home has an ongoing repair and renewal program in place. Areas for further improvements have been identified at this inspection, they include: the need for a cover on the radiator in the hallway next to the ground floor lounge, this was too hot to touch and could be a burn hazard; one bathroom upstairs has wallpaper coming off the wall and there was no top to the cold water tap so this could not be used; the shower head in the shower room was lose and the door to the room did not close properly. The management team should conduct a full assessment of the environment and ensure it is fit for purpose. On the day of the inspection, there was water leaking through the ceiling in the ground floor lounge. The home took immediate steps to address this problem. There is a sign in the ground floor bathroom telling staff that items such as soap and razors should not be left in the bathroom, however we saw bars of soap and razors left in the bathroom. We noticed that some calls bells were out of reach of people, and a quilt left on top of the drier in the laundry room could present as a fire hazard. The kitchen was clean and tidy and in good order. Daily temperature records are being maintained for the fridge and freezer showing appropriate temperatures to maintain good food safety. There also evidence that the cook is checking the temperature of food before it is served. There are risk assessments in place in relation to preparation, cooking, and cooling of foods. There is a cupboard in the kitchen where cleaning products are kept. This cupboard needs to be locked to ensure chemical products that could cause harm to people are safely stored. We saw the oven and grill cleaner left out on a window sill, the warning on this product include ‘causes burns’. Greater care needs to be taken to ensure such products are stored safely when not being used by staff. The laundry area has good systems of infection control. Soiled items of bedding and clothing are taken to the laundry in yellow clinical waste bags, the DS0000004216.V373470.R01.S.doc Version 5.2 Page 23 staff put on gloves and put their hands inside the clinical waste bag to empty clothing into the washing machine. DS0000004216.V373470.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is poor. Staffing levels in the home meet the needs of the people who live there. Recruitment practices at the home need to be more robust to help safeguard the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen to interact well with people living in the home throughout the day; residents were at ease making requests and asking for assistance. There is currently no manager for this home, however staff spoken to were clear about their lines of accountability and were able to tell us who they would speak to if they had any queries. Staff are aware that management support is available from the manager at the sister home – Chasewood Lodge. There is a member of catering staff in the kitchen between 8:00 am and 2pm to prepare breakfast and lunch. The evening meal / snack is prepared by care staff. Staffing rotas for three weeks in November/ December were examined DS0000004216.V373470.R01.S.doc Version 5.2 Page 25 and demonstrated that there are sufficient staff to meet the needs of the people who live there. The home has access to maintenance support when they require it. Four staff files were requested, three personnel files were seen. One staff file told us that this member of staff had previously left Chasewood and been reemployed. A further CRB, PoVA first and references were not taken up on the second employment. This is not in line with good employment processes. Criminal Record Bureau (CRB) are in checks in place for the remaining two files seen. There was no evidence to show that two references have been taken up prior to these staff starting to work at the home. There is no evidence of supervision for one person, and only one record of supervision for another person. The homes’ training matrix was seen. This shows us that staff are receiving a range of training. Certificates were seen for training in diabetes, report writing, food and hygiene and manual handling. The training matrix shows that many of the staff have undertaken fire training in 2008. Records show that staff have received training in ‘Holistic Dementia’ in 2003/ 2004; staff would benefit from refresher training to ensure they are up to date with current practices and legislation. According to the training matrix, the total number of care staff within the home is fourteen. This shows that three out of the fourteen staff who are trained to NVQ 2. The AQAA informs us that seven staff have this qualification. The provider could not give a suitable explanation for this variation. DS0000004216.V373470.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35,36 and 38 Quality in this outcome area is poor. The procedures used to keep people’s money safe protect people from financial abuse. The home has no systems in place to monitor quality performance. Staff are not receiving formal supervision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: DS0000004216.V373470.R01.S.doc Version 5.2 Page 27 There has not been a registered manager at the home in excess of 18 months, and the manager of the sister home is currently managing the home. This means she has to split her time between the two. Information from the Annual Quality Assurance Assessment (AQAA) tells us that the home is looking for manager. This was completed by the manager at Chasewood Lodge and was of a poor standard. The document was hand written and difficult to read and did not tells us how the service meets the needs of peoples daily lives at the home. There is no formal quality assurance system. The owner states that he makes regular visit to the home, however, no formal record of the visits are maintained. The owner told us that he would forward details of the home’s quality assurance the day after the inspection, no information was received by us. There is no evidence that people who live at the home, relatives or stakeholders are involved in making decisions about how the service is delivered or asked their opinion. The management ream must develop a robust quality assurance system to assist them in running the home well and involving those who use it. The home needs to ensure that records about staff training is kept up to date and information requested at inspection about all staff is accessible. The home is not providing staff with regular formal supervision opportunities. Health and safety checks are being undertaken, and these were up to date with the exception of PAT tests (Portable Appliance Testing). There was evidence available to show that the fire system and the emergency lights had been serviced in the past 12 months. There is a contract for the testing of water including temperatures and bacteria, this is completed quarterly and records are available all appears to be safe. Records are maintained for accidents, incidents and injuries at the home. These records were found to be incomplete. Five of the residents’ financial records and money were checked. The money held matched the records. This meets the requirement set out in the last inspection. The home has made some improvement between the last key inspection and random inspection, not all these improvements have been sustained. DS0000004216.V373470.R01.S.doc Version 5.2 Page 28 The management team must put in place a system that will assist them to monitor progress of improvements. DS0000004216.V373470.R01.S.doc Version 5.2 Page 29 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 2 1 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 1 18 1 2 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 x x 3 1 x 2 DS0000004216.V373470.R01.S.doc Version 5.2 Page 30 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 OP8 Regulation 13 Requirement Advice from other professionals must be sought when there is a change in physical or mental wellbeing. Such as in the case for weight loss. This is to ensure that all individuals receive appropriate treatment and care. Strategies for effectively monitoring and dealing with any challenging behaviours, must be clearly detailed in individual care plans. This is to ensure that there is consistency in care that maintains individual’s and staff safety. Staff drug audits need to be undertaken to ensure all medications are accounted for. This is to ensure that all medication is accounted and staff can easily identify where there are any discrepancies and how they occurred. Staff must undertake training DS0000004216.V373470.R01.S.doc Timescale for action 30/01/09 2 OP8 13 02/01/09 3 OP9 13 02/01/09 4 OP18 13 02/01/09 Page 31 Version 5.2 related to safeguarding that is up to date and in line with the Local Authority policy and procedures. This will ensure that staff are able to identify abuse and to respond appropriately to protect residents. As far as practicable an 02/01/09 environment that is free from hazards must be provided for the people living at the home. This will safeguard their health and well-being. Sufficient information must be secured to determine the fitness of potential employees before they start working at the care home. To include: • Two written references, including where applicable, a reference relating to the person’s last period of employment, which involved work with vulnerable adults. • A full employment history, together with a satisfactory written explanation of any gaps in employment. • The outcome of a Criminal Record Bureau (CRB) disclosure and checks against the Protection of Vulnerable Adults register (PoVA). This will ensure that the home’s staff recruitment practices safeguard people living in the home. 5 OP38 13 6 OP29 19 02/01/09 DS0000004216.V373470.R01.S.doc Version 5.2 Page 32 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 OP2 OP9 Good Practice Recommendations Residents should receive a contract or statement of terms and conditions on the day of their admission. The purchase of a refrigerator thermometer to monitor the maximum, minimum temperatures to ensure that all medicines are stored in compliance with their product licences is advised to be purchased. The standards of health and safety management within the home must be reviewed. This should include the testing the safety of all electrical appliances used in the home. Wherever possible service users must be offered choice and the opportunity to exercise some control over their lives. This should be demonstrated in a person centred care plan and reviewed regularly to reflect changing needs and abilities. 3 OP33 4. OP14 DS0000004216.V373470.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000004216.V373470.R01.S.doc Version 5.2 Page 34 - 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. 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