Inspection on 09/06/05 for Chasewood Lodge

This inspection was carried out on 9th June 2005.

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 Lodge 23/03/10

Chasewood Lodge 06/01/10

Chasewood Lodge 17/01/09

Chasewood Lodge 12/12/07

Chasewood Lodge 23/11/06

Chasewood Lodge 13/04/06

Chasewood Lodge 02/02/06

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 CV7 9GE Lead Inspector Suzette Farrelly Unannounced 9 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chasewood Lodge Address Mcdonnell Drive Exhall Coventry West Midlands CV7 9GE 02476 644320 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Chasewood Care Ltd Ms Maria Christine Edwards PC Care home only 35 Category(ies) of OP Old Age (24) registration, with number DE (E) Dementia- over 65 (11) of places Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 4 October 2004 Brief Description of the Service: Chasewood Lodge Care Home is registered to provide care to 35 elderly people. The home has specialist registration to provide care to 11 elderly people with dementia. Chasewood Lodge is situated in a cul-de-sac and lies next to the M6. The nearest town is Bedworth and can be reached by car. There is no local bus service to the home. Since the last inspection work has commenced on the new building to extend the current facilities and provide an additional 70 care beds. The Commission for Social Care Inspection is currently processing an application for a variation to the current registration. In order to achieve the new build, the bungalow that previously accommodated six service users has been demolished. Those service users have transferred to temporary shared accommodation in the main building. As rooms become available the temporary shared accommodation will be reverted back to single occupancy. A ground floor room has been temporarily converted to provide an additional lounge area and overlooks the garden and aviary. Access to the upper floors of the main house is via passenger lift or stairs. A small secure garden area to the rear of the home remains and is accessible to service users. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 10:30 am and was completed at 18:30 that evening. All the communal areas and the small garden were seen and a number of the residents bedrooms. On arrival most of the residents were in the main lounge singing along to music and playing maracas. A member of staff was sing along and joining in the activity. The environment is in need of attention in various places. At this time a new extension of 70 beds is being built and the re-decoration will occur when the two buildings are joined. The manager must however ensure that repairs to furniture and the lighting in the home are dealt with as soon as possible. The garden area is small at the moment to protect residents from harm due to the building works; this area catches the sun most of the day and the residents can easily get in to the garden area. Four residents files were examined and three care staff were formally interviewed. Discussion took place with the manager and senior carers concerning some of the outcomes of the inspection. No relatives were seen, however, eight residents were spoken to in depth and other residents were observed and polite conservation took place. Residents spoken to stated that they liked the home and felt that they were looked after well and their needs are met. The provider was present at the end of the inspection to participate in the feedback. What the service does well: The staff have good communication skills and it was noted that they had formed good professional relationships with the residents and there was a sense of warmth and comradeship. Through observing and discussion it was apparent that the staff are aware of the complex needs of older people who are frail and those who have dementia. Training in Dementia care is also very good. The policies and procedures for new employees are very good, and the home has a suitable induction programme for all new care staff. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 6 The administration of medication is good and staff spoken to were confident and able to discuss issues related to medication in a professional manner. What has improved since the last inspection? What they could do better: The home must ensure that they fully assess all residents prior to admission to ensure that the needs of the resident are recognised and planned care is devised. The care plans do not give clear direction to the care staff, these must be modified and more information must be available. The care plans must also be evaluated monthly. These records must indicate clearly which care is being evaluated and where change has occurred a new care plan must be devised. Daily records of the residents’ day must be made clearly stating what needs have been met and which are outstanding. This information should also contain information concerning changes in health and well being. The furniture in the residents’ bedrooms must be in good repair and any furniture that is broken must be replaced and/or repaired. The unpleasant smells in the same rooms must be dealt with and the manager must ensure that the overall cleanliness of the home is appropriate. The lighting must work in all areas and in some the lighting is dim and the manager must consider how this can be addressed and inform the Commission. The home must also ensure that risk assessments for individual residents are completed and that care plans are written to minimise risk where needed. All residents, with their permission, should be weighed monthly or more often if there is evidence of weight loss. The manager must ensure that all care staff receive supervision six times a year and good records with all the detail are kept and available for inspection when requested. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 7 The home must ensure that there is an accurate complaints procedure and that this information is available in the reception area as stated by the manager and senior staff. 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. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 5 Each resident has a written contract of terms and conditions of the home, which ensure their human rights. Not all residents are assessed prior to entering the home and the service cannot ensure that the needs can be met. Prospective residents and/or their family are able to visit prior to admission offering them the choice to move to the home. EVIDENCE: Most residents have a social service contract. This clearly states the conditions under which they may remain in the home and the responsibility of the home, social services and the resident. The home also has a separate contract for private paying residents, which contains similar information. All residents are charged the same rate and no third party or top up rate is asked for. Three residents files were examined and it was noted that there are assessments and care plans from the social service manager for the resident. The home has only recently started assessing residents before admission. One Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 10 format was seen. The information gathered is not enough to ensure that all the needs of the resident are checked before admission. There are no mental health or risk assessments. The manager discussed this and agreed to make changes to the format for future admissions. On the day of the inspection the home was able to show that it is capable of meeting the complex needs of the resident group. Two staff have started a course in Dementia Care and were able to discuss the specialist care required, and most care staff have attended a three-day course in the care of people with dementia. It was seen during the inspection that the communication skills of staff are good and they have suitable relationships with the residents. Care plans seen are poor and do not give adequate direction related to the care needs of the residents increasing the risk of inconsistent care and possible oversight of care by new and less experienced staff. Three care staff were formally interviewed and a further five staff were spoken to; all showed an understanding of the needs of this group of residents. Through discussion with the staff it was shown that residents and/or their family are encouraged to visit prior to admission to ensure that the home is suitable for their needs. This can be seen in the daily diary and visitors signing in book. It was noted during discussions with staff that the home has an open visiting policy and a good attitude to pre-visits from residents and staff. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The residents’ health, personal and social care needs are not clearly defined therefore there may be an oversight in care causing risk of harm. The residents’ health care needs are poorly assessed and this could possibly result in harm and an oversight in care. The administration of medication is good and the residents are protected from harm by the home’s policies and procedures for dealing with medicines. The residents feel they are treated with respect and their right to privacy is upheld increasing the residents feeling of self-worth. EVIDENCE: Three residents’ profiles were examined and it was found that the care plans are not detailed and this could result in the oversight of care. There is a monthly statement made by the key worker; this did not evaluate the care that is prescribed and it could not be confirmed how changes in care needs are decided. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 12 There were no care plans to deal with poor mobility and the risk of falls. The home was unaware that this is required by the Department of Health to reduce injury as a result of falls. The last review seen in one of the profiles was in October last year and there is no indication when the next review is to be held. There was also not indication that the resident and /or family are involved. The manager stated that new formats were sent to the previous inspector for comment; this is to be followed up to determine if the new format is suitable. There were no care plans in the files seen to deal with oral care and it could not be evidenced that issues related to cleaning teeth and maintaining clean mouths is carried out. The home has no risk assessments for the residents concerning nutrition or the development of pressure damage. The district nurse due to pressure damage and injury to their legs sees one resident. The home has not devised a care plan guiding staff on their role in assisting these wounds to heal. From the examination of four residents profiles it was apparent that none had been weighed since November 2004, this could increase the risk to residents of complications due to unrecognised weight loss in some residents. Other risk assessments related to mobility and falls had not been completed since 2003 or 2004. Overall the lack of assessment of the residents needs could lead to reduced quality of life and a risk of harm due to an oversight of care. The medication ordering, storage and administration was examined and staff spoken to were aware of the procedures and those who administer medication have received training. The medicines are properly stored and the records examined are all up to date. Non-prescribed medication was discussed with the staff and the manager, a policy and procedure for Homely Medication was not available at the time of the inspecction. Throughout the inspection it was observed that staff knock on residents’ doors, offer choices and ensure that all personal care and consultations are conducted in private, this assists in maintaining the residents privacy and dignity. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 The service offers a reasonable lifestyle experience related to social, cultural and recreational interests resulting in an acceptable level of well being. The residents are supported and encouraged to maintain contact with their family and friends maintaining mental well being. There is limited opportunity to make contact with the community, which may result in reduced social skills and increase the risk of poor self esteem. The residents have three meals a day and are offered a choice each time in suitable surroundings increasing their experience of socialisation and pleasant experience of dining. EVIDENCE: Music was playing in the main lounge and some residents were singing and playing maracas. Other residents were sitting watching or quietly snoozing. There was no formal activity programme available at this time and records of ad-hoc activities are not maintained. Residents spoken to stated that they had lots of things to do during the day and enjoyed the experience of living at the home. Books, a selection of various music, magazines and newspapers were seen. The service also has a collection of dolls, two prams and soft toys, this is recommended to assist with the mental well being of those with dementia. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 14 A carer has been given the responsibility to develop activities in the home; ideas for the development of activities were discussed. The carer has minimal experience in developing activities, but is enthusiastic and willing to experiment and learn. It was established through discussion that relatives, friends and others might visit when they wish; there are no restrictions. During the course of the inspection no visitors were seen. There are various lounge areas; a large reception area and the residents may also see visitors in their own rooms if they wish. Relatives and friends are informed verbally of the visiting policy and how to maintain involvement in the care of the resident. There is limited contact with the community. Staff stated that the hairdresser visits weekly and there is a local church service monthly. Some residents go out with relatives and friends and there are occasional trips out with the home. There were no records to demonstrate what trips had occurred or are planned. The meal was served in three dining areas, a choice of mashed potatoes, sausage and baked beans or cheese and potato pie and baked beans was offered. The residents were not asked what size portion they would like; two residents were offered more when they had finished eating. The inspector ate with the residents and noted that the meal was bland in taste, however, most residents were seen to eat the meal and when asked stated that it was OK. Residents were offered assistance where required in a quite and professional manner, encouraging independent eating where possible. One resident did not want their dinner and left the table, it was noted that the staff did not offer an alternative or give a supplement. Staff informed that the resident did this and would eat later. There was no record in her care profile concerning difficulty with her diet. This could result in weight loss and as the home does not consistently weight the residents, gradual weight loss could go unnoticed. As the inspectiont took place on a sunny day the dining area was light and cheerful due to the daylight from the wall and ceiling windows. It was found that the experience of sitting with the residents and observing the staff gave a mixed picture of staff encouraging some residents to eat and appearing not to take action when needed. The kitchen was seen, it is planned to up date this area to be able to meet the needs of a larger service. Records for cleaning and temperatures of the fridges and freezers have been kept up to date. It was noted that food is not dated before putting into the fridges or freezers and uncooked meat was seen stored above the cheese, these practices increase the risk of food poisoning. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The complaints policies and procedures contain alll the information required and the manager deals promptly with concerns and complaints when she receives them. The service protects residents from the risk of abuse increasing their feeling of safety and increasing a good experience of life. EVIDENCE: The home could not initially find the procedure for complaints; this was located before the end of the inspection. The information gave suitable information. The home has received two complaints since the last inspection; investigation records and responses to the complainant were seen. Complaints information is kept in the reception area, staff spoken to were aware of the complaints procedure concerning the home and knew where to locate the complaint form. The home has good policies and procedures for the protection of vulnerable adults. To date there have been no allegations or suspicions of abuse and staff spoken to were able to discuss issues related to this area with confidence. The policy and procedure guiding carers on how to deal with verbal and physical aggression from residents was also good. The above policy and procedure does not guide staff on how to react to visitors who may be verbally or physically aggressive, this may result in harm to the carer and the resident if not dealt with well. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 16 It was pleasing to see a policy and procedure in relation to the use of advocacy services, and the home encourage residents without relatives or friends to use these services. There is no evidence of the Department of Health guidance notes on the Protection of Vulnerable Adults and staff spoke to had only a vague idea about how this document affect their working practice. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 25, 26 The environment is varied throughout in relation to safety, maintenance, comfort and cleanliness. This might reduce the experience of quality of life for the residents. The residents are able to move freely around the home and there is suitable equipment to assist with mobility increasing the quality of life of the residents. EVIDENCE: The maintenance in the home is varied. The lounge areas and main corridors are in a reasonable state of décor and repair. The manager discussed the changes to be made when the new building is completed and joined to the existing home. Broken furniture and poor décor were seen in three of the four bedrooms seen and two had unpleasant smells. One bedroom had a dirty carpet. The broken furniture could result in injury to carers and residents and the visual impact of broken furniture and poor décor might affect the experience of quality of life. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 18 There are no en-suite rooms and the residents must use communal toilets and bathrooms. All rooms seen had commodes. In one room the cover was torn increase the risk of cross infection and difficulty in maintaining cleanliness. The home has three assisted bathrooms and a shower room; this is sufficient for the number of residents. There is a small back garden area with a bird aviary for the residents to use; this area will be expanded when the new building is completed. The sun shines in this area during most of the day and residents can enter the garden from two separate doors from the rear of the home. The home has grab rails in the corridors, toilets and bathrooms and there is a hoist and a standing hoist to assist with mobility. The upper floors can be reached using the shaft lift. There is a call bell system throughout the home, it was noted that the main lounge/dining room does not have a call bell. This was discussed and the provider stated that he would look into this and have one fitted. The lack of a call bell could result in carers not being able to summons help and residents not being able to call a carer if needed. Two wall lights were not working, and the bulbs were replaced during the inspection when this was pointed out to the manager, the other light had lowlevel lighting. The lighting must be at a suitable level to ensure that the residents are able to see well avoiding accidents and incidents. The laundry is tidy and clean and fitted with suitable equipment to meet the needs of the home. There was a large quantity of lint and fluff in the tumble drier this could result in infection and the possibility of fire, this was not immediately removed when identified as a concern. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 There are well trained and sufficient numbers of staff for each shift. The home’s recruitment policies and procedures support and protect the residents from harm. EVIDENCE: From observation, discussion and the care staff rosters it was noted that there are enough staff on duty at all times to meet the assessed care needs of the residents. There is very little change in staff and the home has employed few new staff recently. There are designated domestic staff employed to clean the home, however as some areas were seen as unclean and there were unpleasant smells it is questionable that there are sufficient hours to ensure that all the home is kept clean and tidy. There are two cooks and two kitchen assistants who cook and prepare all food. The care staff are required to finish the tea and ensure that the kitchen is left clean and tidy. Through discussion with the staff and records it was found that over half of the care staff have achieved a qualification in care, and two staff were in the process of completing a certificate course in the care of people with dementia. During the inspection staff were seen communicating well with residents and demonstrating good care practices. On two occasions staff were seen talking Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 20 over residents to each other about issues that residents would be unable to participate in. This was discussed with the manager who stated that she would remind staff of the need to include residents in conversations. Five staff records were examined and it was confirmed that all the checks required ensuring the safety of the residents was completed prior to employment of new staff. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 The manager is suitably qualified, however there are a number of elements of the homes’ operation that are not properly managed. Staff are not offered supervision as frequently as required and this could impact on the quality of care of that is given to the residents. EVIDENCE: The service has been managed by the same person since 1997, through discussion it was shown that she is suitably qualified and the staff are aware of who they should report to. From various issues raised during the inspection there are areas that the manager has not consistently monitored such as care planning and evaluation of care. The records of quality monitoring showed resident and their families surveys, monitoring of some systems such as medication and some self-monitoring of Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 22 the environment and the home. These had not been analysed to determine where changes are required. This can impact on the service provided to the residents reducing the level of good care and ensuring that they remain safe and free from harm. Supervision records were seen for five care staff, these were incomplete and insufficient information was available. This was discussed with the manager and the difference between guidance, supervision and discipline was explored. The manager stated that she would develop a more suitable format for supervision. Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 2 3 x 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 x 2 x x 2 x x Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Schedule 3(1)(a) Requirement Timescale for action 31.09.05 2. OP7 3. OP7 4. OP8 5. OP8 The registered manager must ensure that a full pre-admission assessment is carried out on all prospective residents to ensure that their needs can be met. 15 The registered manager must Schedule ensure that the care plans reflect 3(1)(b) the needs of the residents and give clear and concise guidance to the staff. 15(2)(b)(c The registered manager must ) ensure that there is clear Schedule evidence that the care planned is 3(1)(b) evaluated monthly and changes are made to precribed care as required. 12(1) The registered manager must 13(1) ensure that there are risk assessment for falls, nutrition Schedule and pressure damage completed 3(3)(n) for all residents on a monthly basis. Where a risk is determined a care plan must be devised describing the actions to be taken to minimise the risk. 14(1)(a)( The registered manager must 2) ensure that all residents are 17(1)(a) weighted at least monthly and Schedule where this is not possible an 3(3)(m) explanation must be available in Schedule the residents records. E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc 31.08.05 31.08.05 31.09.05 31.08.05 Chasewood Lodge Version 1.30 Page 25 4(13) 6. OP10 The registered manager must develop suitable policies and procedures for dealing with homely medication. 4(1)(c ) The registered manager must 16(2)(m)( ensure that there is a record of n) activities that take place in the Schedule home and that staff maintain a 1(9) writen record of residents participation. 12(1)(a) The registered manager must 13(1)(b) ensure that it is clearly recorded in the reisdents profiles the actions to be taken by staff when a resident refuses a meal. The action taken and outcome must be recorded. 13(4)(a)(c The registered manager must ) ensure that raw meat is not stored above cooked food as this increases the risk of cross infection and possible food posioning. 22(1)-(6) The registered manager must Schedule ensure that the Complaints 4(11) Policy and Procedure are up to date and have the correct information available, this must be available in the policy and procedure files and in the reception area. A copy of the completed document must be sent to the Commission. 39(h) Areas of the home are poorly 13(4) maintained. The registered 23(1)(2)( provider and registered manager must audit the fixtures and a) fittings in the home and ensure that these are maintianed and safe for the residents and staff to use. 23(2)(n)( The registered manager must p) ensure that all the lights in the communal and bedroom areas are working and that there is adequate lighting available to E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc 13(2)(4) 30.10.05 7. OP12 30.10.05 8. OP15 31.08.05 9. OP15 31.08.05 10. OP16 31.08.05 11. OP19 31.09.05 12. OP20 31.08.05 Chasewood Lodge Version 1.30 Page 26 13. OP21 14. OP22 15. OP24 16. OP24 17. OP25 18. OP26 19. OP26 20. OP33 minimise the risk of falls to residents. 23(1)(a)( The registered manager must 2)(j) ensure that the commodes are in good repair and that staff clean them appropriately. 23(2)(n) The registered provider must ensure that there is a call bell facility in the main lounge of the home to enable residents and staff tp summons assistance if required. 16(1)(2)( The registered manager must c)(d) ensure that the furniture in the 23(2)(e)(f residents bedrooms is in good )(j) repair and where required broken furniture is either repaired or replaced. 12(4)(a) The registered manager must 13(4)(a-c) ensure that all residents have an 23(2)(m) individual locked facility for private and personal items. If the resident does not wish to have this facility this must be recorded and signed by the resident and/or their representative. 23(1)(a)( The registered provider must 2)(p) ensure that there is adequate lighting in all the communal and private areas of the home. 13(3) The registered manager must 16(2)(j)(K ensure that the lint in the tumble ) drier is removed on a regular basis to minimise the risk of infection and possible fire. 12(1)(a) The registered manager must ensure that the unpleasent smells in some resident bedrooms is appropriately dealt with and where necessary the floor covering is replaced. 24(1)(a)( The registered manager must b)(2)(3) ensure that results from surveys and audits are analysed and actions takne to modify the service and improve service outcomes. E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc 31.10.05 30.09.05 31.08.05 30.09.05 31.08.05 31.08.05 31.08.05 30.09.05 Chasewood Lodge Version 1.30 Page 27 21. OP36 18(1)(2) 19 (1)(a)(c) The registered manager must ensure that all staff receive supervision six times a year and clear and concise records are maintained and available for inspection. 31.08.05 22. 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 OP18 OP18 Good Practice Recommendations The registered manager is advised to develop a policy and procedure to guidae staff on how to deal with verbal and/or physical agression from relatives and visitors. The registered manager is adviced to policies and procedures from the DoH Guidance regarding Protection of Vulnerable Adults including the role of managments and other staff and the implications of inclusio onto the POVA list The registered manager is advised to examin the number of domestic hours allocated to the home and determin if these are adequate to meet the needs, size and problems of poor cleanliness and offensive smells in the home. 3. OP27 Chasewood Lodge E53 s4215 Chasewood Lodge v231843 090605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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