Inspection on 03/08/05 for Chaxhill Hall

This inspection was carried out on 3rd August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chaxhill Hall 24/02/09

Chaxhill Hall 04/08/08

Chaxhill Hall 03/08/07

Chaxhill Hall 10/01/07

Chaxhill Hall 08/11/05

Chaxhill Hall 17/02/05

Chaxhill Hall 19/08/04

Chaxhill Hall 17/02/04

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

CARE HOMES FOR OLDER PEOPLE Chaxhill Hall Chaxhill Hall Chaxhill Nr Westbury-on-Severn Gloucestershire GL14 1QR Lead Inspector Janet Griffiths Unannounced 3 August 2005 09:30am 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. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chaxhill Hall Address Chaxhill Nr Westbury-on-Severn Gloucestershire gl14 1QR 01452 760717 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) Mr Peter Albert Whitehouse To be appointed Care Home 36 Category(ies) of OP Older People (35) registration, with number LD Learning Disibility (1) of places Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) To accommodate one named service user under the age of 65 years of age. Date of last inspection 17/2/05 Brief Description of the Service: Chaxhill Hall Care Home is situated alongside the main A48 trunk road between Gloucester and Westbury upon Severn. It is a pleasantly adapted Victorian house offering comfortable rooms. The accommodation consists of thirty-two single and two double rooms, twenty-two of which have en suite facilities. Communal facilities consist of three large lounges, two on the ground floor and one on the first floor, and two dining rooms. The first floor is accessed by a shaft lift. There is a garden and patio area for residents to enjoy in the fine weather. Car parking is available at the front of the building. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over six hours on one day in August 2005. Opportunity was taken to tour the premises, examine records and talk to staff and residents. Approximately ten residents and three staff were spoken with. One of the residents had a visitor who gave their views of the service to the inspector. The home does not have a manager at present as the previous acting manager has left. The homes former manager has returned from retirement in the interim until a new manager has been appointed. What the service does well: What has improved since the last inspection? Some work has been done to improve assessment and care planning, although further improvements are required and there was evidence of some staff training and supervision being carried out. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 6 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. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The admission process is managed satisfactorily and residents are given clear information regarding the service. EVIDENCE: There have been few new admissions since the last inspection but those who were new to the home were spoken with at inspection, as was one relative. Two residents had chosen the home because they had had other relatives who had stayed at the home, they had visited residents in the past and their families had chosen the home as it was near to where they lived. Both were satisfied with the choice made, although one stated that he is still uncertain whether he will remain or return to his home. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 9 Another resident who has now been at the home approximately one year, stated that she had settled in but would ideally still be independent in her own home. Of the five residents ‘records seen on this occasion, two had pre-admission assessments completed, although these were very brief and one had a social services assessment/care plan completed. As the homes’ management arrangements have changed very recently a system has to be put into place to identify who will complete pre-admission assessments in the future. Paperwork is available to do this. The home also has a rolling programme for respite/short-stay admissions but there was nobody on respite care at the time of inspection. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 There is a satisfactory care planning system in place, which reflects multidisciplinary working, but this is not accessible to all of the staff, which indicates that staff may not always be properly informed about the most of the needs of the service users. Residents’ are well looked after in respect of their health and personal care needs, with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: The records of five service users were examined on this occasion, and the information found was then cross-referenced by speaking with/observing the residents themselves and the staff on-duty. Initially no assessments were seen, other than one completed by social services, but these were later located in a separate file. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 11 Each record had care plans identifying individual problems, which generally reflected the current needs of the service users. However, there were two needs identified in daily records for ‘wandering’ and ‘attention to a skin flap’ that did not have the appropriate care plans. All care plans show evidence of regular reviews being completed but these should be done with the service user/their relative where possible. Staff complete daily records but do not generally have access to the assessments and care plans that are kept locked in the office. On discussions with staff it was identified that one service user requires two staff and hoist for moving and handling procedures but there was no moving and handling risk assessment in place. It was also noted that this resident has a room on the first floor accessed by a step and it was questioned how this resident and the hoist are transferred into this room. A review of this situation may lead to a change to another room. It was noted that the soft bedrail attached to this divan bed was not fixed securely and could prove hazardous to the resident and must be removed or fixed securely. The implementation of moving and handling and other risk assessments has been a requirement at previous inspections. Reference to outside agencies such as the chiropodist, dentist, continence advisor and the district nurse confirms good multi-disciplinary working taking place on a regular basis and residents themselves made reference to such consultations. The district nurse is currently attending two residents for wound care on a weekly/twice weekly basis and a third resident every three months for injections. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 Residents experience a fairly stimulating life at the home with visitors encouraged and good links with the community maintained. EVIDENCE: The home did have an activities co-ordinator who visited the home weekly to offer a variety of stimulating activities, but she has recently left. It was reported that currently the staff try to organise some daily group activities, but one to one stimulation is less evident for those who do not wish to or are unable to participate. A large group were enjoying a quiz game during the afternoon and one resident and his daughter who were spoken with related that they had enjoyed a game of bingo the previous week. However, another resident spoken with stated that she had informed staff that she did not wish to take part in such group activities and had found it very tiring and suffered backache following a trip to Prinknash Abbey. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 13 A trip to Weston has been planned for the following week, when the manager hopes 18 residents and 5 staff will participate. Several residents mentioned that they were looking forward to this. A notice board in the hall advertises entertainers who are visiting the home. Entertainment had been planned for the evening of inspection and further entertainment was due in September. The mobile library was visiting the day of inspection, the hairdresser visits weekly and regular church services/communion take place. The home is quite successful in fundraising for outings and entertainers, involving both staff and residents. Only one visitor was spoken with on this occasion, but she confirmed that she is made to feel welcome in the home and was also encouraged to join in the activities organised. From speaking with residents it was clearly demonstrated that they are able to exercise choice and control over their lives. One newly admitted resident was sat in the garden watching the gardener painting a railing around the pond. The residents had chosen the colour they wanted, from white to green. This resident had also bought some fish for the pond that he enjoyed feeding each day. Two other residents had made out a list indicating which dining room should be served their meals first each day. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 14 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) No standards in this section were checked on this occasion. EVIDENCE: Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 15 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 & 26 Residents live in a homely environment, which would benefit from further attention to the décor, maintenance and cleanliness in some areas. EVIDENCE: A tour of the premises was carried out with the acting manager and findings compared with the list compiled when she did a recent check with the proprietor. The current part-time maintenance arrangements have proved less than satisfactory and are to be reviewed, as there were a number of outstanding maintenance issues to be addressed. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 16 Further issues identified at inspection were added to this list for attention and are as follows: • A worn armchair in one room to be replaced. • Metal strip on wardrobe needs removing/re-sticking • Extractor fans in en sites to be checked/cleaned • Cracked light shade in upper floor corridor • Upper floor assisted toilet seat to be replaced. • Bolt fixed to outside of en suite door to be removed. • Flooring damaged in one en suite-to be replaced. • A lock to be put onto a store room on the ground floor where alterations are still in progress. Two rooms were identified as odorous during the inspection. It had been suggested at a previous inspection that alternative floor covering could be used in place of carpeting. It was reported that the relatives did not want this flooring replaced but steps must be taken to ensure that offensive odours are eliminated here. The domestic was asked to give the carpet a thorough clean, following our inspection. One other carpet was noted as being very stained and needs either constant cleaning or replacement. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 Staff are well trained and supported and employed in sufficient numbers to meet the residents needs. The procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home EVIDENCE: There were three care staff and the acting manager on-duty during the morning of inspection with three care staff on a late shift. In addition to the above there was a cleaner and a cook. Care staff are carrying out laundry duties currently as the laundry assistant was cooking in the absence of the cook. One cleaner was also on leave. There was also a gardener on-duty. From observations and speaking with services users it was confirmed that there were adequate staff available to meet the residents needs. Staff spoken with had all worked at the home for some time, enjoyed their work and enjoyed a good rapport with the residents, clearly understanding their needs and how to meet them. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 18 They also confirmed the recent training they had received to include medication administration, first aid, food hygiene and moving and handling training and all three staff had completed or were doing NVQ training. Copies of certificates and supervision /appraisal records were seen in staff files. Records of new staff appointed since the last inspection were checked and it appeared that they had commenced work prior to POVA checks being completed. An immediate requirement notice was given. The acting manager was informed of the amended regulations that came into being in July 2004 when POVA checks commenced:• Full career history to be completed from school with an explanation of any gaps • An interview record to be kept • Two written references, one from the last employer where possible and the last reference from a care establishment where appropriate. • Written confirmation that the applicant is physically and mentally fit to work • A photograph of each member of staff and other proof of identification Following the inspection, the proprietor confirmed that he was ensuring that each new member of staff had a CRB/POVA check but acknowledged that staff had been appointed before POVA checks were completed because of the time it took for them to be done. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 19 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 & 38 As there has been no registered manager in the home for some time, the home lacks a consistent management team at the home to support the staff team. There continues to be some practices that do not promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: After working as acting manager at the home for a considerable period of time, the CSCI made the decision in discussion with the provider that for a number of reasons this person would not be suitable to be registered manager at the home and this position became vacant. An interview for a prospective manager has been arranged for the week following the inspection and it is anticipated that if successful the CSCI will receive a completed application form as soon as possible. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 20 In the meantime the former manager has returned from retirement to manage the home in the interim. Residents spoken with were quite happy with the current arrangements, being very familiar with the former manager and satisfied that their lives in the home won’t be disrupted. All said they knew what action to take if they were unhappy with anything in the home and were confident that it would be dealt with. There were several health and safety risks identified that must be attended to. Every resident must have a moving and handling assessment completed with priority to the one resident who needs a hoist for transfers. The room allocated to this resident must also be considered as being no longer suitable and a move should be planned. A programme to guard radiators was introduced but little progress has been made since the last inspection. There is no written evidence to indicate that hot water temperatures are being checked regularly to ensure that the thermostatic control has not failed. In the light of recent publicity regarding a scalding accident to a resident of a home, this must be completed at once and continued regularly. Arrangements have yet to be made for a water test to be completed to safeguard against Legionella. Any areas of the home where maintenance work is ongoing must be secured when unattended to safeguard against accidents. Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 21 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x x x x x x 2 Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 22 yes 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 3 Regulation 14 Requirement An assessment to be completed and a copy of the assessment obtained prior to admission to ensure resident needs can be met. Each service user must have a written assessment completed and reviewed regularly and reviews are to be completed with the service user or their representative where possible.(Timescale of 19/10/04 and 17/3/05 not met) The registered person shall make suitable arrangements to provide a safe system for moving and handling service users by carrying out written risk assessments on each service user and reviewing them regularly.(Timescale of 19/10/04 and 17/3/05 not met) Consult service users about the programme of activities arranged by or on behalf of the care home having regards to the needs of the service users. Ensure that the premises are of sound construction, kept in a good state of repair internally and externally and kept D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Timescale for action 30/9/05 2. 7 15 30/9/05 3. 8 13 30/9/05 4. 12 17 30/9/05 5. 19 23 31/10/05 Chaxhill Hall Version 1.40 Page 23 reasonably decorated. 6. 7. 26 29 16 19 Ensure that the home is kept free from offensive odours. All required documentation as identified in Schedule 4; Regulation 17(2) of the Care Homes Regulations be held in staff files A manager must be appointed and seek registration with the Commission. The registered`person shall ensure that all parts fo the home to which service users have access are so far as is reasonably practicable, free from hazards to their safety 30/9/05 30/9/05 8. 9. 31 38 8 13 31/12/05 30/9/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 24 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Bussines Park Brockworth Gloucester GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chaxhill Hall D51_D03_16402_Chaxhill Hall_v238103_030805_UI_Stage4.doc Version 1.40 Page 25 - 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!