Inspection on 09/08/05 for Chelfham House

This inspection was carried out on 9th August 2005.

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

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

Other inspections for this house

Chelfham House 05/04/07

Chelfham House 26/10/06

Chelfham House 21/12/05

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 Barnstaple Devon EX31 4RP Lead Inspector Sue Dewis Unannounced Inspection 9 August 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. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chelfham House Address Chelfham, Barnstaple, Devon, EX31 4RP 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) 01271 850373 Mr Mark James Hammond Mrs Wendy Margaret Plant Care Home 28 Category(ies) of DE(E) Dementia - over 65 (28), MD(E) Mental registration, with number Disorder - over 65 (28), OP Old Age (28), PD(E) of places Physical Disability - over 65 (28), S(E) Sensory Impairment over 65 (28) Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd February 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 the first floor and a call bell system is installed throughout the home. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on one day over approximately four hours. The manager and the owner were available throughout the inspection. The inspector made a tour of the building, but did not look in all bedrooms. Five service users, three staff and three visitors, were spoken with. A range of policies and procedures were inspected. What the service does well: What has improved since the last inspection? What they could do better: There is still much to be done to the fabric of the building to bring it up to the standard of the care offered at the home, including fitting thermostatic controls to sink taps and much redecoration. There is still some work to be done in Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 6 relation to establishing a quality review system and care plans would benefit from more detail in some areas. When staff, visitors and residents were asked what the home could do better, the one thing that was raised was that staff would like to spend a little more time chatting with residents. 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 D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.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 Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.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) None of these standards were inspected on this occasion EVIDENCE: Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 9 There is generally a clear and consistent care planning system in place that adequately provides staff with the information they need to satisfactorily meet the needs of the residents. The health care needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Four residents’ care files were inspected, including the most recent admission and the most dependent resident. All plans contained photographs and a ‘life story’ of each resident, and contained evidence of resident involvement as necessary. The plans contained comprehensive risk assessments and had all been reviewed monthly. Although the plans had been regularly reviewed, it was noted that some changes to residents’ care needs had not been recorded on their plans. It is recommended that any changes in care instructions are immediately recorded on the resident’s plan. The file of the most recent admission contained a detailed pre-admission assessment, that had been completed by the manager when she had initially visited the resident. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 10 The plans contained detailed instructions to care staff when there were particular healthcare needs. However, there were not so detailed instructions to staff on day to day general care needs, and it is recommended that more detail in this area is recorded. Plans contained evidence of involvement of health care professionals, and it was possible to track where a concern had been identified and investigated. The manager reported good relationships with health care workers, with District Nurses visiting twice weekly at present. Medication records were checked and all MAR (Medication Administration Record) sheets now contain photographs and room numbers of the individual resident. MAR sheets are checked on arrival at the home to ensure their accuracy. There is now a policy and procedure in place for dealing with individual doses of medication that may have been refused. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 Social activities that are offered provide stimulation and interest for residents. Residents are able to maintain contact with family and friends. Meals are nutritious and offer a healthy and varied diet for residents. Residents views are sought regularly and they feel that they can affect the way the home is run. EVIDENCE: An activities organiser is employed at the home for twice weekly sessions. Records are kept of the individual residents’ likes and dislikes. On the day of the inspection some residents had been taking part in gentle exercise classes and others had had a manicure. Residents were eager to tell the inspector how much they had enjoyed their exercises. Regular residents meetings are held and residents have an opportunity to say if they are concerned about anything, if they want different activities or different menus. Minutes of the meetings were seen and it was possible to trace where issues had been at a meeting then dealt with by the manager or the owner. The inspector spoke with three visitors who had been visiting two residents. All visitors spoke highly of the care their relative received, and felt that they were kept informed and involved with any issues of concern. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 12 The relatives made comments like ‘ Always get offered tea and coffee now matter how busy they are’, ‘Would recommend it to anyone’ and ‘Haven’t found anything to complain about’. Residents told the inspector that the food was always good, though sometimes they were given too much. Menus looked wholesome and varied and residents are asked on Sunday to choose their lunches for the following week. As well as the main menu, one resident is on a low fat diet, and another menu is prepared for a resident who has very specific likes and dislikes. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 13 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 and 18 Residents are confident that their concerns will be listened to, taken seriously and acted upon. Staff training ensures residents are protected from abuse. EVIDENCE: There is a simple complaints procedure and a log is maintained that contains all complaints forms. The manager and inspector had a discussion about what constitutes a complaint and it was decided that is residents raise concerns, but do not want to complete a complaints form, the manager will record brief details of the concern in a separate book. Two residents that the inspector spoke with, said that if they had raised any concerns they had been quickly dealt with. In line with recommendations from the previous inspection the home’s WhistleBlowing Policy has been revised to inform staff of their duty of care to report any suspected abuse. The home’s Adult Protection procedure has also been revised to bring it into line with local multi-agency procedures. The inspector spoke with two care staff who both had a good knowledge of differing types of abuse and the action they would follow if they suspected abuse. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 14 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, 21, 24, 25 and 26 The standard of the environment within the home is improving, providing residents with a safe, comfortable and homely place to live. EVIDENCE: The home is clean, comfortable and homely. There is an ongoing programme of maintenance that started when the owners took over the home earlier in the year. Though some areas have been upgraded, many items have been repaired and replaced which are not easily noticeable, such as a new septic tank and rewiring. The owner will start on more obvious improvements such as major redecoration and refurbishment once the health and safety issues have been addressed. Two new toilets with wheelchair access have been installed on the ground floor. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 15 The inspector looked in several bedrooms and all were very individual and contained many personal items. There are several communal areas where residents can sit and watch TV or be quiet if they wish. New easy chairs are on order for the main lounges. There is currently no easy access to the garden except through the kitchen. This is being addressed as are other issues relating to the general fabric of the building. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 16 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 and 30 The deployment and numbers of staff available throughout the day are sufficient to meet the needs of the residents. Residents’ needs are met by well motivated and trained staff. EVIDENCE: On the morning of inspection the manager, 4 care staff, a cook and a domestic were on duty, and the owner was also present. Staff and residents said that they felt staff had enough time to comfortably meet the needs of the residents and had time to sit and chat with them. Two care staff were spoken with and both were experienced and had received training in Fire precautions, moving and handling and protection of vulnerable adults. One is working towards NVQ 3. Residents and visitors were very complimentary about the staff and one commented that they ‘liked all the staff’ and another felt there was a good mix of young and older staff. There is an ongoing programme to ensure that a minimum of 50 of staff achieve NVQ 2 by the end of 2005. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 17 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, 32, 33, 36 and 38 The home is well managed and this results in practices that promote and safeguard the health, safety and welfare of the residents. EVIDENCE: The manager has recently achieved the Registered Managers Award and has several years experience of working with older people. The two care staff that were spoken with confirmed that they receive regular supervision and felt that they were listened to if they raised issues with the manager. Though there is no formal system for reviewing the quality of care at the home, residents and visitors said that the manager was ‘especially approachable’ if there were any issues about quality. A formal system must be set up, reviewed and made available to resident. All policies and procedures have now been dated and show a review date. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 18 The fire log book was well maintained and staff now sign to confirm they have received fire training. The owner confirmed that all windows above ground level are fitted with restrictors. Thermostatic control valves have not been fitted to all sink taps, but the work is in progress. A new kitchen is due to be fitted in October of this year. Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 19 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x 3 x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x x 3 x 2 Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 20 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 OP33 Regulation 24 Requirement 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 15/06/05 not met) Timescale for action 17/11/05 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. 2. 3. 4. Refer to Standard OP7 OP7 OP12 OP19 Good Practice Recommendations You are recommended to include more detail of how staff will meet residents day to day basic care needs, on their plans You are recommended to ensure any changes to care needs are imediately recorded on residents care plans You are recommended to ensure a minimum of 50 of care staff achieve NVQ 2 by end of 2005 You are recommended to continue to upgrade the premises D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 21 Chelfham House 5. OP38 You are recommended to fit thermostatic conrols to all sink taps to which residents have access Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Suite 1, 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. Extracts may not be used or reproduced without the express permission of CSCI Chelfham House D54-D06 S62357 ChelfhamHouse V243120 100805 Stage 4.doc Version 1.40 Page 23 - 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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