Inspection on 17/01/09 for Chasewood Lodge

This inspection was carried out on 17th January 2009.

CSCI found this care home to be providing an Adequate service.

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 Lodge 23/03/10

Chasewood Lodge 06/01/10

Chasewood Lodge 12/12/07

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 12/10/2009.

CARE HOMES FOR OLDER PEOPLE Chasewood Lodge Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE Lead Inspector Julie McGarry Unannounced Inspection 17th January 2009 05:00 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.V373815.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. Chasewood Lodge DS0000004215.V373815.R01.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.V373815.R01.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 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 is registered to provide care for a 107 people. Ninety-five beds are registered 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 ‘Information book’ and this contains information and photographs of both Chasewood Lodge and the new home known as Chasewood Manor. Chasewood Lodge DS0000004215.V373815.R01.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 £416 and £435 per week. Other additional charges include the hairdresser, chiropody, personal toiletries, newspapers and magazines. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality 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. Three inspectors carried out this key inspection. The inspection visit took place on 17th January 2009 between 5:00am and 18th January 2009 5:30pm. 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. 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. The care of five people living in the home was identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence of the care provided is matched to outcomes for the people using the service. Care plans and monitoring records of other residents were examined randomly. Our assessment of the quality of the service is based on all this information plus our own observations during our visit. 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 deputy manager. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? Requirements set at the last inspection have been met. Alarm systems have been fitted to all fire doors to alert staff if anyone opens these reducing the risk of people living there leaving the home without staff knowing. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 8 An improved system for sharing information between staff at the end of each shift has been developed. Overall medication management and administration has improved. 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. The summary of this inspection report can be made available in other formats on request. Chasewood Lodge DS0000004215.V373815.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 Chasewood Lodge DS0000004215.V373815.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): Standard 3 was assessed. Quality in this outcome area is good. People who are considering moving into the home benefit from having their care needs assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of four residents admitted since the last inspection was examined to assess the pre-admission assessment process. Assessments provided details of their health and personal care needs, which include information on physical and mental health history, mobility, nutrition, communication and activities. The availability of this information helps to Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 11 ensure that the specific care needs of each person can be identified and used to help complete a plan of care. Records on people’s files show that information was received from health and social care professionals, as well as individuals’ relatives prior to people moving in. Where possible, records of people’s own wishes about their prospective move to the home have been recorded. The provider said that it was usual practice for him and the manager to visit people who are considering moving into the home to undertake an assessment of their needs and abilities. One record seen provides information to show that this person visited the home prior to moving in. Chasewood Lodge DS0000004215.V373815.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 and 10 Quality in this outcome area is Adequate. People can be confident that their needs are being met. There are minor issues with the management and administration of medication that may result in mistakes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents receive personal support in the way they prefer and require as evidenced through observations during the inspection, discussions with staff and examination of records. For example, on the morning of the first visit not all residents were up and dressed. Residents arose at varying times and made choices about where to have breakfast and what they wished to eat and drink. Case files of five residents identified for case tracking were examined in detail. Each person has a plan of care, daily records and monitoring records. Care plans are generally based on information secured during the initial care needs assessment, and kept under review. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 13 Information in people’s care plans are not always well organised, and can make access to information difficult. Further work needs to be done to ensure care and risk assessment plans are accessible and detail all information needed about people’s needs. One person’s records said they require the assistance of one carer when walking outside as they may abscond, this will ensure they remain safe. Preadmission records informed the management and staff that this person had absconded in the past. This was recorded in the care plans, there was no clear information in the plan of care to inform staff of the action to take if they should abscond. It is important that this is available so that all staff act consistently and ensure that appropriate action is taken quickly. Risk assessment plans are not always available for the identified needs of residents. For example, four people’s records looked at show the need for support with the management of skin integrity. All four files lacked clear information and risk assessments on what care needs to be provided, and how risk is minimised. However, staff spoken to were able to tell us what was required to minimise the risk of skin damage and knew the equipment needed. A risk assessment plan is absent for one person who has bedrails. This information is needed in care plans to help ensure that bed rails are used appropriately. Staff were also seen to support one person in wheelchair without the use of footplates. This person’s care plan did not have information or a risk assessment plan in place to show that risks for this have been assessed. Assessments for the absence of footplates should be carried out and records maintained to ensure staff are providing appropriate care and minimising the risk of injury. There is evidence of good recording practice with some people’s records. For example, one person’s records shows that their mobility needs are deteriorating. Their GP was contacted, and care plans updated to reflect the change in needs and level of staff support required. Equipment needed to support this person was also available. Another record shows that staff are maintaining weight records and have made a referral to one person’s GP for blood tests to determine cause of weight loss. A dietician was also contacted. Staff spoken to demonstrated a clear understanding of this person’s nutritional needs. Observations during both visits showed that staff were following care plan guidelines in relation to meeting this person’s nutritional needs. The home has introduced a ‘handover’ system at the start of each shift. We observed one ‘handover’ and found staff to communicate with each other in a Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 14 concise yet comprehensive way. Staff complete a record of the meeting and ‘sign over’ the keys. A ‘head count’ is carried out to ensure staff know where all residents are. Throughout the inspection staff were observed to communicate well with each other. There is evidence on some files that families have been involved in the reviewing of their relative’s care plans. There were no written records to tell us if families who were not involved had declined. Care plans looked at evidence that people have ready access to a GP and other health professionals locally including, dentists, dietician, opticians and chiropodists. People told us that ‘staff will get the doctor if I’m unwell’. Families also said that they were kept informed of any incident that affects their relative. Staff spoken with had a very good understanding of the people’s individual needs. Information provided by staff reflected that detailed in the care and risk assessment plans. Staff were able to inform us of training they have received that guides them in the way care is to be provided. All the staff spoken with were enthusiastic and had a positive attitude on promoting peoples independence. Medication administration and management was examined in all areas of the service. Each unit has its own medication trolley and storage area. A senior member of staff who has received medication training administers the medication in each unit. Time was spent examining four Medication Administration Records (MARs) on each unit and checking the medication, recording, storage and disposal of medicines. There have been some improvements in the management and administration of medications, the MARs are now completed when the medication has been given and there were no unexplained gaps. There were some issues found on the first day of this inspection. The senior carer dispensed a medication in the evening for one person who required this at 07:00 am. The procedure was for the carer on nights to administer this in the morning. This is unsafe practice as the carer in the morning does not have access to the medication and therefore cannot check that no mistakes have been made. This was discussed and an immediate change was made, a senior carer will now commence her morning duty at 07:00 am to administer this person’s medication. The provider told us that as more people are admitted to the service there will be senior carers with the skills to administer medication employed to work nights. The controlled drug cupboard was checked, this contained medication for four people. The amount of medication found in the cupboard had not been recorded in the control drug book as required by law and there was an Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 15 excessive amount of one medication. Cross-checking medication received with the amount given told us that all medication is accounted for. The Deputy Manager arranged for the excess medication to be removed on the first day of the inspection, ensured that all medication was properly recorded and accounted for and set up an system to check the controlled drugs weekly to ensure that these are managed appropriately. There was clear information about the use of ‘ as required medication’ and staff recorded why they had given the medication. General medication was given appropriately and there were no concerns about this. It is recommended that hand written administration records are signed by two people to minimise mistakes and that printed prescriptions are not altered but re-written if needed. Staff who have received training in medication were knowledgeable about the medicines they were administering and knew where to get further information if required. The provider has also employed a person who checks the medication every two weeks to ensure that medication is administered as prescribed. Records of these were seen and showed that there have been some minor errors that have been appropriately dealt with. Administration of medication was observed on two units and it was noted that staff did this in a professional and caring manner ensuring that the resident took their medication before signing the MARs. During the two days it was noted that all people living at this service are treated with respect and dignity. Personal care was carried out in privacy and all those seen were appropriately dressed in clean clothes and looked comfortable and neat. Each person was able to spend time where they choose and it was observed that the staff and those living there had a comfortable and trusting relationship, with laughter, smiles and respect. Chasewood Lodge DS0000004215.V373815.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, and 15 Quality in this outcome area is Good. The home offer activities led by an activities co-ordinator so that people in the home can maintain their enduring interests. People benefit from a nutritious and varied diet and have sensitive assistance to eat their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs an activities co-ordinator with responsibility for devising a programme of individual and group activities for the benefit of people living in the home. We are told that the activities person visits each unit twice a week. Care plans looked at show formal activities take place at the home, for example, physical fun games, Cludeo and an outing to Walsall Illuminations. However, daily records do not reflect the informal activities that care staff provide. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 17 Residents were observed to spend time in the privacy of their own rooms or join others in communal areas for company or meals. People were seen to ‘potter about’ at the home and move freely between units on the same floor. We observed breakfast in one unit. People were offered a choice of a cooked breakfast or cereals. People were also offered a hot drink of their choice. One person from Scotland prefers porridge for breakfast. Staff told us that this person sees this breakfast as part of her culture. We sat with people during their Sunday lunch in each of the units. People were offered a choice of roast beef or turkey accompanied with roast potatoes, creamed potatoes, vegetables and Yorkshire puddings, fish was available on request. A separate gravy float was offered so that each person could make their choice to have this added. Meals were well presented and looked appetising. Good practice at meals time was observed for people who require liquidised diets. The cook ensures food portions are liquidised separately to maintain the colour and appearance of the foods where possible. Meals times are ‘staggered’ in each unit to ensure food is provided at suitable temperatures. A member of kitchen staff accompanied the ‘hot trolley’ around the home to assist care staff. Staff were seen to assist people where necessary. One to one support was offered to people who remained in their beds during meal times. Meal times gave a sense of a social occasion as people chatted and laughed during the meal. Meal times were relaxed and unrushed. People we spoke to told us that they enjoyed the food and it was plentiful. One resident spoken to commented: ‘Got no complaints, the food is good’ ‘they give you plenty, can’t get through it all, no room left for my yogurt’ Another person was heard saying ‘ I’m full up’. There is evidence that people are able to maintain links with their families and friends. Also visits from members of the clergy are arranged 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. Relatives spoken to commented positively on the care being provided: ‘care is good with X’ ‘ X is always clean and tidy’ Chasewood Lodge DS0000004215.V373815.R01.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): 16 and 18 Quality in this outcome area is good. Each person can be assured that their concerns and complaints will be investigated and that they will be listened to. Protection of people living at the home is good and that they are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy and procedure available and families are given this information. Relatives spoken to felt they could approach staff or the managers should they have any concerns. Comments from relatives include: ‘Staff keep in touch with you’, ‘[We are] reassured that my mother was in the home’. ‘very good , no complaints’ ‘No issues, would speak to carers if I did’. Staff were aware of how they should deal with concerns and complaints and it was evident that minor concerns are dealt with day-to-day. These are not always recorded. It is good practice to do so, so that concerns can be audited to determine if there are any trends and to ensure that concerns do not escalate into complaints. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 19 Records of complaints were seen, these showed that the management respond to families when they complain in a suitable manner and that the families are satisfied with the outcomes. Letters of concern were also seen that the management had sent to the local hospital in relation to the return of a person who lives at Chasewood Lodge. This tells us that the service is concerned that all people are treat with respect and dignity and there needs are met. Staff spoken with were fully aware of how they should respond in cases of alleged or actual abuse. They could explain what would be abuse and were aware of the ‘Whistle Blowing’ process. There have been a number of issues reported under safeguarding in relation to the management of care and safety of the people who live there. In one instance two people exited the building through a fire door, which they managed to open. The police returned them. As a result of this incident the provider has ensured that all exit doors are fitted with alarms to alert staff if someone exits the building, and further checks have been put into place to check that everyone is in the building. Other issues have been related to the care provided by the home and actions taken to ensure each persons well being. There has been no evidence at this time to indicate that the service has been at fault. Record keeping does not always indicate the good work that is carried out and this has made it harder to ascertain any culpability when investigating alleged abuse. Chasewood Lodge DS0000004215.V373815.R01.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): 19 and 26. Quality in this outcome area is good. People live in a comfortable, clean and organised home that allows them to move around freely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection there were 62 people living at this home that can accommodate 107 people, 12 of whom are younger people suffering from dementia. The home has three sections, the older part of the building, which is a converted large family residence, a new building over two floors for older people with dementia. This area is purpose built and is divided into small units of 12 to 13 people in each area. The final area is 12 beds divided into three 4 bedded units for younger people with dementia. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 21 All the areas were seen to be clean and tidy and free from unpleasant smells. Domestic staff were spoken with and told us that they have enough time and are supplied with all materials to ensure that the home remains clean. Care staff ensured that the small dining areas and lounges remained comfortable and inviting during the day. The fire doors have recently been fitted with an alarm system to alert staff if any one exits through these doors. Staff are all aware of this and told us they would respond promptly to ensure that no one can wander outside without assistance. The laundry is done on the premises and this is managed well ensuring that cross infection is minimised. The kitchen is located in the older part of the building and meals are staggered to ensure that each unit receives fresh hot food, which is delivered using a heated trolley. The kitchen was organised, clean and all temperature tests are completed as required. A recent Environmental Health Visit told us that they were satisfied with the management of this area. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 22 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 good. There are enough staff on duty to ensure that each persons needs are met. Staff are trained and supported to increase their skills and knowledge to enable them to offer good care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each unit is staffed separately to ensure that there are enough staff in each area to meet each persons’ needs. The rota confirmed that over the two days of this visit there was enough staff on duty. The rotas also told us that there are sufficient staff available at all times. Each unit has a senior member of staff during the day shifts to ensure that the needs of each person are met and to supervise the carers. There are three deputy managers, two have completed their Registered Manager Award (RMA) and one is near completion of this course. There are also staff to work in the laundry, kitchens and to maintain the cleanliness of the home. A handyman is available for repairs and to ensure that maintenance checks are completed. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 23 Three files of staff employed since the last inspection were seen. These contained all the information required to ensure that they are suitable to work with vulnerable people. Induction is carried out for all new staff. The Learning Skills Council induction standards are used and these are signed off by a senior member of staff to demonstrate that the person has completed these. Staff also attend other training to ensure they have the skills to meet each persons needs. Further dementia training is being carried out in February along with Moving and Handling. Bereavement Training has been booked for April 2009. Staff are paid to attend training and support to improve their knowledge and skills. Supervision records told us that this is not consistent for all staff. It is important that all care staff receive formal supervision six times a year and that this is recorded. The deputy manager informed us that not all supervision is recorded as some is informal and occurs on a daily basis. Staff told us that they felt supported by the management and could express ideas and concerns. They also told us that they felt low in moral due to other professionals questioning their ability to care and felt that they were not recognised for their good work. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 24 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, 25, 36 and 38 Quality in this outcome area is adequate People who use this service can be assured that it is managed well and that their safety is considered. Management of process and procedures is adequate and this has created failures in some areas which may impact on the experience of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was not available during this inspection visit. She has managed the home for about 13 years and has a lot of experience managing this type of service. She is supported by three deputy managers, two have Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 25 completed there Registered Managers Award (RMA) and one is completing hers. One of the deputy managers was on maternity leave at this time. There are a number of senior carers and at least three on duty at all times during the day shifts from 08:00 to 22:00. This indicates that the staff available is suitable and that they have the skills to meet the needs of the people who live there. The personal monies of people living in the home are kept securely in separate bags and records of income and expenditure are kept. An audit of three residents’ personal monies was found to have errors, which gave one person a £12 credit. The management of people’s monies needs to be more robust. The quality auditing system was not robust and although systems to improve the service are in place these are not assessed to ensure that they are working and the improvements have been sustained. This was discussed with the provider and the deputy manager. The deputy manager told us that she had put into place further auditing for medication on the first day of the visit and would discuss further changes with the manager on her return. Staff have the opportunity to attend a variety of training both for statutory training and specialist training. All staff who work with the younger people have received training so they can meet their needs. The ‘handyman’ who has recently completed training in testing all electrical equipment has carried out pat testing. The fire records are maintained and these told us that staff have regular fire practices and feedback is given to ensure that they are up to date with the process. There is a contract with a firm to check the fire systems and equipment as required by law. A gas landlord certificate was seen and showed that this has just been completed and all gas equipment was fit for use. Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 X 3 Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 12 Requirement Care plans should state actions to be taken to minimise risk for those individuals who have been assessed as ‘being at risk’. This will ensure that all staff are fully aware of the risks and actions to take to minimise the risk. Timescale for action 13/03/09 2. OP8 13 A full assessment and risk assessments must be available for those people who require bed rails for safety. This is to demonstrate that bed rails are used appropriately to maintain safety and not to restrain. 13/03/09 3. OP9 13[2] Two care staff must sign hand written information in regards to medication prescribed by the GP. This will minimise the risk of mistakes. 13/03/09 4 OP9 13[2] A system must be implemented DS0000004215.V373815.R01.S.doc 13/03/09 Page 28 Chasewood Lodge Version 5.2 and used to ensure that stock control of controlled drugs is maintained. This is to minimise the risk of medication abuse. 5 OP9 13[2] Medication must be dispensed and administered by the same person and at the same time. This will minimise the risk of mistakes in dose, wrong medication and the person the medication is given to. 6 OP33 24 The quality auditing system that is robust must be improved. A report must be produced that summarises the findings of the auditing and sets actions and targets for improvement. This will ensure that the service is acting in the ‘best interest’ of those using the service and demonstrate planned improvements. 7 OP35 17 Sch 4 Accurate records of all monies kept for people at the home must be maintained. This is to ensure that the risk of financial abuse is minimised. 13/03/09 13/03/09 13/03/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 29 1. OP7 Where appropriate the person and/or their relative should be involved in the planning of care and reviews to demonstrate their agreement. Where this is not possible a record should be kept to indicate this. Formal supervision should take place six times a year and records maintained on each staff file. 2. OP36 Chasewood Lodge DS0000004215.V373815.R01.S.doc Version 5.2 Page 30 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.V373815.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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