Inspection on 21/12/05 for Chelfham House

This inspection was carried out on 21st December 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

Chelfham House 05/04/07

Chelfham House 26/10/06

Chelfham House 09/08/05

Chelfham House 22/02/05

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Chelfham House Chelfham House Chelfham Barnstaple Devon EX31 4RP Lead Inspector Sue Dewis Announced Inspection 10:00 21 December 2005 st 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 Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 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. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chelfham House Address Chelfham House Chelfham Barnstaple Devon EX31 4RP 01271 850373 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) Mr Mark James Hammond Mrs Karen Jane Hammond Mrs Wendy Margaret Plant Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (28), Old age, not falling within any other category (28), Physical disability over 65 years of age (28), Sensory Impairment over 65 years of age (28) Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Chelfham House is a privately owned, care home, providing accommodation and personal care for up 28 service users, over the age of 65 years. The home is registered to provide care for older people, who may be frail, suffer from a dementia illness or may have a mental disorder. The home is situated in a small rural hamlet, on the outskirts of Barnstaple in North Devon. The large two storey detached property stands in its own large grounds, with commanding countryside views from many aspects of the building. There is a newer ground floor extension, which was completed in 2000.The home was not purpose built as a care home, but has been adapted over the years to meet the needs of service users. There are 22 single bedrooms and 2 double rooms. Of these 17 have ensuite facilities. There is a passenger lift to all floors and a call bell system is installed throughout the home. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four hours one day just before Christmas 2005. The home had been notified that an inspection would take place within three months and had returned a pre-inspection questionnaire, information from which was used to write this report. The inspector spoke with one relative, four residents in private and three others in a group setting. Comment cards were received from three relatives. The inspector also spoke with five staff in a group setting and the owner in private. Three staff files were inspected including recruitment information. Three resident’s files were also inspected. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that it obtains two satisfactory references for all staff prior to them starting work at the home. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 6 A copy of the report into the quality of care at the home must be sent to the Commission and a copy made available to residents and their representatives. Staff should ensure they do not refer to residents as room numbers when recording information in the communications book. The upgrading of the premises should continue including fitting thermostatic valves to all sinks that residents have access to. 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. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 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 the following standard(s): 3 Prospective residents are assured that their care needs can be met. EVIDENCE: Three residents’ files were inspected, including the files of the two most recent admissions. These contained a completed preadmission assessment form. The resident and a visitor confirmed that the needs of each resident were being met. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7 and 10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet the needs of the residents. However, improvements to the recording systems will ensure residents care needs are met consistently. The health care needs of residents are generally well met. EVIDENCE: Three resident’s files were inspected. One belonged to a resident with high needs, one to a recent admission and one was in a recently updated format. The plans were comprehensive and gave information to staff on how to meet the day-to-day care needs of each resident. The care plans also included risk assessments, moving and handling assessments and GP and district nurse visits. The plans had all been recently reviewed by the resident’s key worker and showed where changes to care had occurred. Individual daily recordings are made on the care plans. A communications book is also maintained. This book refers to room numbers rather than the name of the resident. Staff felt that this was necessary to maintain confidentiality. Concerns have been raised by a visiting district nurse over the care provided to Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 10 a resident who developed pressure sores. This resident had been moved to another room, but the records had not been changed to show this. The practice of referring to room numbers rather than residents would have exacerbated this problem. This was discussed in detail with senior staff who immediately instructed care staff to refer only to residents by name. The member of staff who is responsible for inducting new staff told the inspector how new staff are instructed in respecting privacy and dignity when giving intimate personal care. Residents told the inspector that staff were always very good at respecting them and in particular their privacy. Residents confirmed that they are given the choice as to whether a male member of staff gives them personal care. There have been no further concerns raised by the primary health care team over the health care needs of residents. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 11 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 the following standard(s): All of these standards were inspected at the last visit. For more information please see the previous report of 9 August 2005. EVIDENCE: Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 12 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 the following standard(s): All of these standards were inspected at the last visit. For more information please see the previous report of 9 August 2005. EVIDENCE: Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 19 and 26 The standard of the environment within the home is improving, providing residents with a clean, safe, comfortable and homely place to live. EVIDENCE: There has been extensive refurbishment to the building, and a new kitchen has recently been fitted and the garden has been landscaped. There are several comfortable communal areas around the home where residents can sit and meet. Most residents have their own single room which have been personalised. All areas of the home were clean and pleasant and there were no unpleasant odours. There is a continuous programme of redecoration through the home. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 The procedures for the recruitment of staff are not robust and do not offer protection to residents. Residents benefit from having their needs met by well trained staff. EVIDENCE: There was evidence on file showing staff had received a range of training, including, Health and Safety, Food hygiene and Holistic Dementia Care. Staff confirmed that they had received this training and some are doing NVQ as well. Residents said that they felt that staff were well trained and able to care for them. One resident commented ‘I feel confident that if I need help its there, if not I’m left alone in peace’. Recruitment files were inspected for three staff, including the most recently appointed member of staff. Though there was evidence of proof of identity and an application form on all three files, one did not contain any references. In order to safeguard residents, staff should not be allowed unsupervised access to any resident prior to all required checks being carried out. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 The home is well managed and this generally results in practices that promote and safeguard the health, safety and welfare of the residents. EVIDENCE: Minutes of meetings were seen to show that the manager regularly consults with residents, and residents confirmed that they attended these meetings and felt that their views were acted on. Completed questionnaires on the quality of care at the home were also seen. However, the Commission has not been supplied with a report on these quality assurance measures. No money is maintained by the home on behalf of residents. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 16 Records were seen that showed staff had recently received fire training and staff displayed a good knowledge of procedures to be followed in the event of a fire. The owner has received quotes to have thermostatic control valves to individual sinks and this will be incorporated into the maintenance budget for next year. Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X X X 2 Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 18 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 OP29 Regulation 19(1) Requirement You are required to ensure you do not employ a person to work at the care home unless you have obtained the information and documents specified in paragraphs 1 to 7 of schedule 2 (This relates to obtaining references) You are required to establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided at the care home in consultation with service users and their representatives. The registered person shall supply to the Commission a report of the review and make a copy available to service users (Timescale of 17/11/05 not met) Timescale for action 31/01/06 2. OP33 24 13/07/06 Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 19 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. 3. Refer to Standard OP7 OP19 OP38 Good Practice Recommendations You are recommended to ensure staff refer to residents rather than room numbers in the communications book You are recommended to continue to upgrade the premises You are recommended to fit thermostatic controls to all sink taps to which residents have access Chelfham House DS0000062357.V271846.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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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