Inspection on 12/12/07 for Chasewood Lodge

This inspection was carried out on 12th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chasewood Lodge 23/03/10

Chasewood Lodge 06/01/10

Chasewood Lodge 17/01/09

Chasewood Lodge 23/11/06

Chasewood Lodge 13/04/06

Chasewood Lodge 02/02/06

Chasewood Lodge 09/06/05

Chasewood Lodge 04/10/04

Chasewood Lodge 18/05/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

Churchill House Nursing and Residential Home

Field Farm House

Church Terrace Nursing & Residential Home

Fountain Court

The Forbury

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

CARE HOMES FOR OLDER PEOPLE Chasewood Lodge Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE Lead Inspector Ashley Fawthrop Key Unannounced Inspection 12th December 2007 09:00 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 Chasewood Lodge DS0000004215.V356532.R02.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. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chasewood Lodge Address Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE 02476 644320 02476 644320 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 Ms Maria Christine Edwards Care Home 107 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (95) of places Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 12 Dementia over 65 years of age (DE) 95 The maximum number of service users to be accommodated 107 2. Date of last inspection 20th June 2007 Brief Description of the Service: Chasewood Lodge Care Home is a registered care home, providing care to elderly men and women with a diagnosis of dementia, with a facility to take younger adults with early onset dementia. The home is situated in a cul-de-sac and lies next to the M6 with easy access to Nuneaton, Coventry and Bedworth. There are local shops, which are accessible and the nearest town is Bedworth. There is local bus service to the home. The home has recently been extended to provide 107.95 beds for older people with dementia and 12 beds for younger adults with early onset dementia. The old and new buildings are linked The home provides unitised care in both the new and old buildings, each unit has separate lounge, dining, assisted bathrooms and toilet facilities. Residents are free to walk around the building and use facilities on any of the units. Throughout the home there are also additional quiet communal areas and a new hairdressing salon is located on the ground floor. Information about the home is available in a document entitled an ‘Information book’ and this contains information and photographs of both Chasewood Lodge and the new home known as Chasewood Manor. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 5 There are parking facilities at the front of the building, and further spaces at the entrances to both the new and old buildings. The manager has advised that the current fees for a place in the home is between £408 and £418 per week. Other additional charges include the hairdresser, chiropody, personal toiletries, newspapers and magazines. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out without prior notification and was conducted by one inspector over the course of one day. The inspector would like to thank everyone who took the time to talk to them and express their views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, adult protection issues, reports from other agencies, i.e., the Environmental Health Officer, and correspondence following the last inspection. This information was used to plan this inspection visit. The inspector case tracked three people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspectors assessed all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. The inspectors spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these people was looked at. Where possible, contact was also made with external professionals to obtain their opinions about the quality of services provided at the home. What the service does well: Information continues to be available to people before they move into the home this allow them to make to make an informed choice about the home. People are assessed before they move into the home so that the home is able to assure both them and their representatives that their needs can be met. Relatives said that they were kept up to date with changes in health care needs. Records seen show that staff continue to be safely recruited. Two written references are obtained, and Criminal Records Bureau Disclosures and POVA checks are undertaken to ensure the people they employ are “fit” individuals to care for the residents at the home. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 7 Training for staff continues to be taken seriously by this home, a training plan is in place and a high number of staff have achieved National Vocational Qualifications (NVQ) in care and senior staff in management. An Environmental Health inspection earlier this year produced a positive inspection report confirming the home manages food hygiene in the kitchen to a good standard. Comments received about the staff were positive and included comments such how friendly and helpful know how kind and caring they are. Other comments included that the food was great. What has improved since the last inspection? What they could do better: There is little evidence that people living in the home are involved in the planning of their care. The care plans appear prescriptive as though staff have decided what is best for the person rather than ask them what they would want. More needs to be done to demonstrate that people who live in the home have the opportunity to exercise choice in relation to all aspects of their life in the home, including: leisure and social activities, meals and other areas associated with daily living. Activities should be centred around the person and should include any past interests they might have. They should be targeted at the ability of the Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 8 individual to make them meaningful. While group activities have there place they should not be the only activities offered. There were mixed comments about the standards of care at the home. Further consultation with people and their relatives should be undertaken to develop individual life histories to be used as part of care planning. Some survey questionnaires have also been completed and returned to the manager. These should now be formulated to produce an action plan to demonstrate where improvements, if required, are being made. This information should then be fed back so that people know that their opinions are important and their ideas and concerns are acted upon. The registered person and manager should look at how the care plans are managed and put in place formal process to check a sample of care plans regularly so that when people are admitted into hospital the information is accurate and up to date. 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. The summary of this inspection report can be made available in other formats on request. Chasewood Lodge DS0000004215.V356532.R02.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 Chasewood Lodge DS0000004215.V356532.R02.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): Quality in this outcome area is good. Information continues to be available to people before they move into the home so they can make an informed choice about the home. People are able to visit the home and are assessed before they move in, so that the home is able to assure both them and their representatives that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an Information book and this is available to all new people admitted to the home The Handbook contains information about the home, the services it provides and includes a copy of the contract of residence, which outlines rights and responsibilities. As recorded at the last inspection the document to provide all the information that may be required and to answer some questions, it is very detailed and may not be suitable for all to read easily. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 11 The booklet contains photographs of the manager, the owner, some of the staff team and photographs of some meals and the bedrooms, living areas and the gardens from the new building. There is also a statement inviting people to visit the home before they move in. There is a copy of the complaints procedure in the booklet, but this should be more detailed, in keeping with the home’s policy. Since the last inspection the home has been registered to care for younger adults with dementia related illnesses so the information will need to be updated to give people information on how the home will meet their needs. This must be done before people are admitted to this unit. People spoken to on the day of the inspection said that they did have the opportunity to visit before they moved into the home and staff showed them around and explained the routines of the home and some of the services offered. Assessments continue to be done by the manager and senior care staff or if not, one of the senior team. Following the assessment, people and or their representative are informed in writing if the home can meet their needs. The pre assessment information for people who had been recently admitted into the home were seen. Generally the assessments seen had been completed well and gave good information to formulate a care plan. The home does not provide intermediate care. Chasewood Lodge DS0000004215.V356532.R02.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): Quality in this outcome area is adequate. Care planning has improved but people are not involved, the home does not take social care seriously. The management of medicines does make sure that the health and wellbeing of the people who live in the home is maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for three people were case tracked in detail during the inspection, people and staff were spoken with to see if the care documented, reflected their individual needs. Care plans read showed that the manager and staff had made improvements updating care plans where there was evidence that the health and well being of people had changed, this gives staff the information they need to provide the best care. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 13 There was no evidence seen to show that people and / or their relatives are involved in the care planning process. The care plans were written in a prescriptive way and the information appeared to come from what the staff and the manager felt was the best care rather than asking what the person or their relative what they wanted. People spoken with said that they were made aware of hospital appointments and felt that they were kept up to date with changes in care needs as they attended review meetings. Care plans continue to focus on specific areas of physical or mental needs rather than the person as a whole. There is very little evidence that the home takes the social and emotional needs of people seriously. Where there is information about peoples social interest this is rarely acted upon. There has been an improvement in the standard of risk assessments are and direction given to staff. One care plan that had been seen as poor at the last inspection had been updated the care plan had been reviewed. This demonstrated that where the needs of the resident had changed risk assessments and care plans had been written to ensure that staff gave appropriate care’ One care plan of a person who had recently moved into the home had been managed, there was a pre admission assessment that showed why a move into the home was needed. There was information about their special needs and the care plan gave staff information on what they needed to do to provide the best care. This gave a good picture of how the care of this person was managed but was not complete as the social care was not completed. People comments about the quality of care was mixed, while some people felt that people were left unsupervised for long periods others said that the staff were very nice and friendly. Other comments were that staff do not understand the needs of people while others said that the food was great, people appeared nice and clean and the staff managed specific areas of care very well. Evidence was available to show that access to GP’s and optician and a chiropodist had improved. We inspected the medication storage facilities and the policies and procedures related to the giving out of medication. There are designated staff who have Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 14 the responsibility to manage the ordering, monitoring and disposal of medications. On speaking to staff they were able to discuss the procedures for administering medication and had a good knowledge of what was good practice such as signing for each persons medications before giving the next out. This reduces the risk of mistakes. The administration of medications was seen, this was seen to be safe. On looking at medication sheets, there was a picture of each person so that new staff could recognise the individual before they give them their medication. Staff continue to sign to record they had administered medicines when they had not there were no gaps in the recording. Where medication are commenced after the commencement date of the pre packed system are recorded on the right date reducing the risk of mistake. The home does have a system to check in medicines received into the home there is evidence that this is routinely adhered to. Quantities of medicines are routinely recorded but staff do not always carry over balances from previous cycles. Audits were difficult to undertake in these instances to demonstrate that staff do administer the medicines as prescribed. Staff clearly crossed off discontinued medicines on the medicine chart but one medicine was left in the cabinet to administer increasing the risk of it being administered by mistake. Medication bought into the home by new residents was recorded on the medicine chart. Inadequate checks had taken place to confirm with their doctor that these were the current medicines prescribed and staff failed to record the exact quantities received. Some supporting protocols for medicines to be administered ‘occasionally’ or when necessary and these were well written and clearly stated when a medicine should be given, why and at what dose. However they were not found for all ‘occasional use’ medicines, particularly if the person was new to the home. Senior staff continue to do an accredited course in the safe handling of medicines and further training is to be purchased. Knowledge of the medicines staff administered was good. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 15 The managerial staff do audit the performance of care assistants on a regular basis to confirm their competence in the safe handling of medicines, but these are not done as regularly as they used to be. These audits need to be reintroduced to raise the standard of medicine management within the home The home continues to have a dedicated medication refrigerator and the temperature was within the correct temperature scale. There was a chart for staff to sign when the temperature had been checked this was up to date. The home has installed a Controlled Drug cabinet there were no Controlled Drugs in the home at the time of the visit. As recorded in the last inspection there were inadequate storage facilities on one unit, however, there is evidence that the home as acted on this an extra cupboards are on order. In the Chasewood Lodge unit, all the medicines were stored in a large metal cabinet in the staff area. This area is hot and medications should be transferred to the extra cupboard space on the units. Chasewood Lodge DS0000004215.V356532.R02.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): Quality in this outcome area is adequate. The home does not take seriously the social and emotional needs of people. Visitors are encouraged to visit freely and relationships are maintained. The food is of a good standard. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues not to employ anyone to specifically organise activities. One of the senior staff organises trips and books regular entertainers. People said that there was a lack of activity in the home and there were few trips out. The home continues to organise for regular entertainers to visit, and there are group activities. Staff were present and assisted people with care tasks and talked, there was no evidence that people had the opportunity to follow any activity that interested them personally. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 17 In many cases people relied on visiting relatives for stimulation. Relatives were seen to come and go freely throughout the day. A number of people were taken out by relatives and staff were seen to assist in getting people ready or making sure that any equipment like wheel chairs were available. Lounges were fitted with music centres with CD’, some games and books and some boxes of things for people to help themselves to. There was equipment available for arts and crafts such as paints and glue this was stored appropriately. Staff said that activities were normally organised in the afternoons in one of the lounges, these include karaoke or movement to music. People visiting the home said that the food was good and some stay for meals on a regular basis. The atmosphere in the dining room was relaxed and staff assisted people with sensitivity and those that needed assistance was offered this at an acceptable pace and the different food groups were explained. Staff said that people are normally offered a choice by showing them what had been prepared when the food came from the kitchen; people were seen to be happy with the choices offered on the day of the inspection. Some of the frailer people did not wish to eat at the same time as others, staff said that they kept the meal and re heated it later in the microwave. Since the last key inspection policies and procedures have been put in place to make sure that the food has reached the correct temperature to minimise the risks associated with reheating high-risk food groups. The head cook checks these policies and the monitoring book is signed when the checks are complete. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. Complaints are taken seriously and concerns listened to and acted upon. However, systems to protect people from abuse need to be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy continues to be on display in the home close to both entrances and is well written policy guiding people who wished to make a complaint. A complaints record was available. Since the last key inspection two formal complaints had been recorded and there have been a number of concerns raised that have been investigated by the Social Services and the Commission. However, the registered person and the manager have acted to improve the quality of care for people living in the home. Details about the nature of the complaint were recorded, there were accompanying letters written by the manager detailing the findings of investigation and what the outcome was. These letters were copies of the originals sent to the complainant. And though it appears that the manager listens to the complainants there was evidence that these are not always taken seriously. made and does take them seriously. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 19 People spoken to said that they know who to complain to and have reported minor concerns to the staff that have been acted upon. Staff continue to attend training in Protecting Vulnerable Adults (POVA). There are policies and procedures relating to the protection of adults that includes a whistle blowing policy. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 20 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 good. People who live in this home are provided with an environment, which for many, meets their needs, is well maintained and is safe and comfortable. The home is clean and odour free and procedures have been put in place for the control of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the home’s old and new build units were undertaken with the manager. In the new build extension, there are three units on each floor. People can safely access all the facilities on the floor they live on and can use any lounge or dining area, any bathroom with its various facilities . Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 21 The new building is tastefully decorated with good quality furnishings in communal and bedrooms. People’s rooms in the new building have all en-suite with a toilet and a washbasin and are all single but two. All rooms have a modern call system that can on only be turned off from where it has been activated. All rooms have suitable locks that allow staff access in an emergency and also give residents peace of mind as they can lock the door. The furniture is modern in design and provides adequate storage for each resident. On both floors of the new building there are rooms for sitting and watching TV, quiet rooms, lounges with kitchenettes and some used for activities. The kitchenettes have a fridge for items of general use such as milk. To make sure these items are stored safely the temperatures should be monitored and recorded. On each floor there are three bathrooms, one assisted, and all bathrooms also have a floor-draining shower. All the bathrooms are very new and at present are clinical in appearance, the manager should explore how these could be made more homely, to provide residents with an environment to enjoy and relax when bathing Chasewood Lodge is the old building has three lounges and the larger lounge also has dining facilities. People have the opportunity to personalise their rooms with personal possessions and items of furniture. These give the rooms an individual feel and ownership for the person occupying it. The bathrooms in this part of the building, of which four were seen, vary in size and equipment used, for example two had hoists into the bath and two were static domestic baths, some areas in the baths had grab rails. All areas were clean and there were no creams or detergents left around that would cause a risk to personal safety procedures for handling soiled linen have improved. The laundry assistant described how dirty items of laundry come in and how clean items go out, the laundry is kept separate and the staff clearly understand the importance of doing this. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 22 There are now safe system for transferring high-risk bedding or clothing, all items are separated into bedding or clothing and put into the appropriate bag. Soiled items now have separate red bags to indicate they require special attention and the laundry assistant has access to disposable gloves and aprons when sorting out what items of laundry require sluicing. This has reduced the risk of cross infection. The home is clean and well maintained and there were no unpleasant odours. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 23 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): Quality in this outcome area is good. People who live in this home receive care from a staff group that is well trained and has the skills to meet their individual needs. Policies in place for recruitment are robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were spoken with during the inspection and one member of staff who had worked at the home for a few months she said that she had had an induction and had undertaken training in infection control, first aid and moving and handling. Others said that they enjoyed working at the home and found the management team to be supportive. There was evidence on staff training files that they receive a good induction on starting at the home there are courses available in moving and handling. Fire safety, medication, Protection of Vulnerable Adults and a 3-day course in dementia care. Staff are also working towards NVQ on levels 2, 3 and 4. On the day of the inspection there were two training sessions taking place these were first aid and an NCFE level 2 certificate on safe handling of medicines. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 24 There is a training matrix for staff at all levels that provide evidence that training is an on going process in the home. Staff attend the training have the skills and competencies to deliver care to residents safely and effectively. Staff continue to be had been safely recruited, they continue to have structured staff files, which confirmed completion of an application form, two written references (one from most recent employer), Criminal Records Bureau Disclosures, POVA checks and confirmation about dated of employment. The home has completed required checks to do all they can to ensure the people they employ are “fit” individuals to care for the residents at the home. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. The manager is experienced and has developed a well-qualified management team. The home does not adequately demonstrate that it is being run in the best interests of those who live there. Systems to ensure the health, safety and welfare of residents are generally well managed and management of medication and infection control procedures have improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has worked at the home for a number of years, and is an experienced health care provider. She has developed a senior team of care staff a number of whom have achieved or are working toward attaining the Registered Managers Award. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 26 The home continues to have a deputy manager and senior carers are given some time in a supernumerary capacity, to undertake some additional lead responsibilities. These include: training, medication, care planning, nutrition and health care liaison. Relatives of people living in the home had been asked for their views about the atmosphere in the home, facilities, quality of meals, cleanliness and other areas such as likes and dislikes. The responses varied, with positive comments thanking the staff for looking after people and taking wonderful care of them. Others said that staff had shown much kindness and care. There were also some negative comments that said people were left unsupervised for long periods of time and there was a lack of activities. The home does not appear to have a quality audit process where this kind of information is acted upon and the results of any action taken fed back to people in a formal manner. Therefore is difficult to find evidence that the home is developing its services taking into account what people want. The home continues to provide a service for people to deposit money and the records for three people was assessed. The records and available balance of money were accurate, and receipts have been kept for purchased items or services such as hairdressing. One relative visiting, said that staff request additional money when the balance is getting low, and that he was aware of how the money was being spent. Records about maintenance of the home for Chasewood Lodge and Chasewood Manor were made available. They are maintained separately. Chasewood Lodge continues to have regular tests made on the fire system including the alarm, emergency lights and fire equipment. No recent concerns have been made, yet there was no evidence that the fire system and emergency lights have been recently serviced, the owner advised that he would forward the records of service when they could be found. The call system has been checked on a monthly basis, and there were no concerns, however as with the fire system there was no evidence available of a recent service. The risk assessments for fire and evacuation were unavailable as they have been recently revised and are on a computer disc that could not be accessed, the manager advised that she would forward copies. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 27 These were all received during the writing of the report and they confirm that tests were undertaken in April 2007. Work identified was completed, but a recommendation was made that the old systems be updated as soon as possible. There continues to be records relating to staff regularly attending fire drills and as reported earlier they are also attending fire training. Other records seen included test of electrical equipment and its installation, service and reports on the passenger lift, the servicing of hoists used to help residents with moving and tests on water including bacteriological and monitoring of temperatures. The maintenance records were available, including tests of the call system, fire alarm, emergency lights and water. The servicing of equipment used in the building was not assessed. There was a fire risk assessment available and operational policy for such emergencies. The manager has improved the policies and procedures for infection control by providing liquid soap in wash areas and dissolvable able plastic bags for soiled linen to be laundered in, so that staff do not handle this, which improves infection control. Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 28 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 3 X 3 X 3 NA HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13(2) Requirement Further locked storage facilities are required to store surplus medication and those awaiting return to the pharmacy for destruction. The purchase of an additional trolley is required to safely transport medicines to the service user in the main house. Previous timescale not met 31/10/07 The controlled drug cabinet must be reserved for the storage of controlled drugs only. 2. OP7 15(20(a) People must be involved in the planning of their care and the care plan must be made available to them. All medicines brought into the home must be checked and the quantities clearly recorded to enable auditing of administration. 31/05/08 Timescale for action 31/03/08 3. OP9 13(2) 29/02/08 Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 30 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 OP12 Good Practice Recommendations Following consultation with people and their relatives’ work should be undertaken to further develop individual life histories. The Users guide should contain the date of the last review and information about it being available in alternative formats. The service users guide should be updated to include how the needs of younger adults will be met before any one is admitted to this unit. 3. OP22 Care plans should reflect that the environment promotes the orientation and independence of residents when moving round the home. 2. OP1 Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 31 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 Chasewood Lodge DS0000004215.V356532.R02.S.doc Version 5.2 Page 32 - 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!