Inspection on 22/05/06 for Chelsham Lodge

This inspection was carried out on 22nd May 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 45 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chelsham Lodge 03/10/07

Chelsham Lodge 05/12/06

Chelsham Lodge 08/11/05

Chelsham Lodge 26/07/05

Chelsham Lodge 14/12/04

Chelsham Lodge 03/08/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Chelsham Lodge Chelsham Lodge High Lane Warlingham Surrey CR6 9DQ Lead Inspector Pat Collins Unannounced Inspection 22nd May 2006 09:20 Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 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 Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 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 Adults 18-65. 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. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chelsham Lodge Address Chelsham Lodge High Lane Warlingham Surrey CR6 9DQ 01883 622168 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) The Avenues Trust Limited To be confirmed Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of service users is: 37 - 60 YEARS Date of last inspection 8th November 2005 Brief Description of the Service: Chelsham Lodge is a care home providing personal care for seven adults with severe learning disabilities. Service users may present behaviours which challenging service provision, autistic traits or have other complex needs. Currently all service users are male. The building is a spacious, detached two - story house situated in a semi-rural location. A large secluded garden is provided also a wheelchair accessible vehicle. Car parking facilities are available. All bedrooms are single occupancy and are on the ground and first floor, accessible by stairs only. Toilet and bathing facilities are within close proximity of all bedrooms. Communal facilities are on the ground floor, comprising of a spacious lounge, an activities/sensory room, a separate dining room, fitted kitchen and utility room. Warlingham village is within easy walking distance of the home. Larger shopping facilities and a wide range of leisure amenities are accessible. The home is close to the Kent and Surrey border and within travelling distance of countryside, parkland and the coast. Service users receive professional specialist input and support. The organisation operating the home is a registered charity and major provider of support services for adults with learning disabilities in the South East of England. Weekly fee charges ranged between £ 1784 and £2888 as of April 2006. Additional charges are for aromatherapy sessions, toiletries, magazines, cigarettes/tobacco and some social activities. Prospective service users and their representatives are informed about the home’s services and facilities in a service users guide document available from the Avenues Trust. Also the home’s latest CSCI inspection report. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for Chelsham Lodge for the inspection year 2006 and 2007. It brings together the cumulative assessment, knowledge and experience of service provision at the home over the past 12 months. It also takes account of the findings of an unannounced inspection visit undertaken by one regulation inspector on 22nd May 2006. The duration of this was eight hours and all key national minimum standards for adults were inspected. A tour of the premises was undertaken and records, policies and procedures were sampled. The ‘acting’ manager, regional manager, two senior support workers and two support workers were consulted. The inspector had contact with all service users though none were able to verbally communicate their experience of life at the home. This was due to their complex needs and communication difficulties. Judgements relating to their welfare were based on direct observations and interpretation of the moods and behaviours of service users. Records and direct feedback from staff, also the content of comment cards received from three visitors also enabled assessment of service users’ wellbeing and the quality of service provision. The inspector would like to thank all who contributed to the inspection process. What the service does well: What has improved since the last inspection? The home’s manager was on long term leave since February 2006. A competent, effective ‘acting’ manager was in place since that time. She is a registered manager from another care home operated by the Avenues Trust Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 6 and has relevant knowledge and experience. The ‘acting’ manager was working towards an NVQ level 4 qualification in the management of care also the Registered Managers Award. Direct observations and feedback from individual staff indicated the ‘acting’ manager provided good direction and leadership to the team. She expressed confidence in the team’s capacity to raise standards and improve service provision. Individual staff were noted to be open to changes in practice and routines for the benefit of service users. A multi agency action plan was being implemented to improve management of challenging behaviours and complex needs. Outstanding speech and language and occupational therapy assessments were stated to be imminent. Staff and service users benefited from the expertise and support of a specialist community team. Senior management within the organisation including a specialist behaviour manager were also supportive and made available additional resources and staff training. Staffing levels on night duty had been increased since the last inspection. A fundamental review of staffing levels for the 24 - hour service was imminent. A new development plan and model of support was being introduced, underpinned by requisite training. Additionally a person centred approach to care planning was being implemented also improved systems for monitoring service users progress. Staff had been afforded opportunities to influence change for the benefit of service users. They had received copies of handbooks containing key policies. These were discussed at team meetings and individual supervision sessions to promote good practice. There was improvement in quality assurance and quality auditing systems. The lounge had been redecorated and new curtains hung which had much enhanced the environment. What they could do better: The ‘acting’ manager was making progress for compliance with outstanding statutory requirements brought forward from the last inspection report. These included updating the Statement of Purpose and Service Users Guide. Staff must undergo refresher safeguarding vulnerable adults refresher training. Improvement is necessary to the physical environment of the home and to personnel records. Care plans must be produced for the management of risks identified in the fire risk assessment and staffing levels require review. It was stated by management that staff were expected to focus more on skills building to enable service users to learn and use life skills and be involved in domestic routines. This was not evident from practice observations at the time of this inspection visit. Individual service users were noted to currently have minimal opportunities for choice in their lives. Staff emphasised this was being addressed through a person centred care planning approach. Initiatives to enhance communication and produce appropriate communication tools could also be considered. The ‘acting’ manager stated that support workers had increased opportunities for service users to engage in activities in the community. It was acknowledged by the ‘acting’ manager that this was an area Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 7 in which staff’s skills and confidence needed further development. She expressed commitment to increasing opportunities for service users to access their local community; also increase choice and independence in their lives. Care plans and care practices did not adequately promote diversity and equality for service users. Examples of this are recorded in the main body of this report. It is acknowledged that management emphasised that the Avenues Trust was committed to putting into practice the organisations policies on equality and diversity. Further related staff training was planned for 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. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in the outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide required updating. This will enable prospective service users and their representatives to have the information necessary to make informed choices about admission. Multidisciplinary assessments support the team in identify and responding to the needs and aspirations of service users. Service users have a statement of the terms and conditions of their residency setting out individual rights and responsibilities. EVIDENCE: The home’s Statement of Purpose and Service Users Guide was revised last year to ensure service provision was accurately depicted. Both documents had been professionally produced. The Service Users Guide was in a pictorial format that was suitable for the people for whom the home is intended. Both documents required updating to reflect changes in management and staffing. It is acknowledged that the ‘acting’ manager stated that the Statement of Purpose had been updated and the draft sent to head office for typing. There had been no new admissions since the last inspection. Pat pre-admission procedures had ensured decisions about admission to the home were on the basis of comprehensive needs assessments carried out to be confident needs could be met. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 10 A fundamental review of care practice was in progress at the time of this inspection. An action plan was being implemented to enable staff to respond to the complex and challenging needs and behaviours of service users. The organisation’s behaviour specialist manager was involved in the preparation and training of the staff team, introducing them to the principles of the ‘active support’ model of care. The training had involved also exploration of values, norms and attitudes. The ‘acting’ manager confirmed new activity plans and record keeping practices were being developed. These will underpin the proposed new model of care being implemented. There was currently significant input from specialist professionals providing needs assessments and support. The ‘acting’ manager confirmed that speech and language and occupational therapy assessments were imminent. Services for individuals with a dual diagnosis of learning disability and mental health disorders were stated to be accessible and also supportive. The home was no longer able to fully meet the needs of one service user whose mobility had significantly deteriorated. The inspector was informed that his care manager was exploring alternative placements for this individual. In the interim two staff supported him when mobilising. Consultation with staff identified ongoing safety issues specific to moving and handling this individual when bathing without provision of a hoist. The ‘acting’ manager was aware and reported having requested a further physiotherapy assessment to determine needs regarding moving and handling equipment. The ‘acting’ manager reported some increase of opportunities in recent weeks for service users to engage in activities in the home and in the community. It was also stated that support workers participated sometimes in community based activities with Surrey Oakland Day Services staff. Whilst acknowledging more could be done the ‘acting’ manager recognised that individual staff needed to build up their confidence when accompanying service users in the community. A staff member stated that the key working system, specifically misinterpretation of the role of key workers by some staff could be a constraint to engaging service users more in activities. This was discussed at the time of the inspection with the ‘acting’ manager who stated this issue had been recently drawn to her attention and will be addressed. There was a contract/statement of terms and conditions of residency on the service user’s file sampled. This contained all relevant elements though it was not produced in an accessible, pictorial format. Contracts between the organisation and purchasers were held at head office. Discussed with the regional manager was the need to maintain records in care homes which detail contract agreements for additional funded hours for named service users. This is necessary to assess the adequacy of staffing provision and establish that 1:1 staffing ratios do not deplete the care hours remaining for the rest of the group to the detriment of these individuals. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 11 Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in the outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. Though care plans were in place these were not all up to date and did not address all needs. Additionally care planning and practice did not fully promote and meet equality and diversity needs of service users. Service users require more opportunities for choices in their daily lives. Whilst risk assessment and risk management practices were overall effective, an increase in frequency of reviewing risk assessments is necessary. EVIDENCE: Shift planning activities allocated specific responsibilities to individual staff. A structured, consistent and organised care environment was promoted which was suitable for the needs of service users. Key workers were allocated to all service users. They were responsible for developing care plans and coordinating care programmes. The community team for people with learning disabilities supported staff in the review and development of guidelines, risk assessments and behaviour management programmes. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 13 The care plan sampled during this inspection whilst holistic lacked adequate consideration of equality and diversity issues. The service manager had identified this also at the time of the latest monthly statutory visit to the home. It was positive to note in the report generated from that visit that the Avenues Trust was committed to being more proactive in making available equal opportunities and diversity training to all levels of staff. Behaviour support plans, risk assessment and risk management strategies were in place. Staff consulted demonstrated awareness of their content. Strategies for deescalation of aggressive behaviours were planned to avert the need for physical interventions. A self - portrait had been produced for the service user whose care was followed up by the inspector. This contained specific strategies for achieving social interaction, communication and independence skills and ensuring a safe environment for this individual. It was of concern that the care plans and risk assessments for this individual however had evidently not been reviewed since October 2004. The ‘acting’ manager stated that care management reviews were mostly overdue. Exceptions to this were service users who were regularly reviewed under the Care Programme Approach. Comprehensive crisis management plans were in place for these individuals. The manager acknowledged that the home should ensure regular internal reviews held and must not delay reviews because care managers were not able to be present. It was stated that care management reviews were being arranged. Person centred plans (PCP) were in the process of being developed. A senior support worker and a support worker had recently undertaken PCP facilitator training. It was intended that facilitators supported key workers and other staff in implementing PCP’s and in the application of the underpinning philosophy and principles. Currently the care documents were a combination of old records and new PCP formats. Some contained symbols & other visual information to aid communication and understanding. There was evidently significant understanding of the behaviours of the service user whose care records were examined. The key worker responsible for producing a written self – portrait for this service user had assessed likes and dislikes based on behaviour observations. Person centred care plans had been formulated accordingly and offered some choices in his life and respected rights. Some staff on duty were observed to be more adept than others in interpreting this individuals gestures, body language and behaviours. These enabled expression and communication in the absence of speech. The ‘acting’ manager was aware of the value of self - portrait information and of behavioural programmes being accessible to staff. She stated that consideration was being given to the adequacy of current systems to provide staff with necessary information. Comments received from relatives/visitors confirmed satisfaction with the level of contact with them by staff. They reported being informed of important matters affecting service users and being consulted about their care. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 14 Risk assessments were sufficiently detailed and comprehensive. A recent incident however demonstrated that all staff had not adhered to the risk management strategy in place to safeguard a named service user. Also discussed with the ‘acting’ manager and a senior support worker were omissions in care planning and staff’s practice for the same service user to address specific individual diversity needs. These were specifically in respect of religion, culture and diet. A senior support worker stated that at the time of a visit from the relatives of this service user last year that his cultural and religious needs had been discussed. It was stated his family expressed their wishes he be offered opportunities for personal choice in these areas of his life. This information had not been recorded in care plans and care records did not reflect considerations to ensure informed choices. It was anticipated that the PCP approach would address this omission. The inspector was informed that a letter had been sent to all relatives to ascertain relatives’ wishes regarding dying and death of service users. This letter had generated telephone contact from the family of the service user whose care was tracked by the inspector. They had sought reassurance that he was well. It was suggested by the inspector that such letters might in future be preceded by telephone contact from key workers with families to avoid unnecessary alarm. Also discussed was inconsistent practice in recording information in daily logs. Some staff recorded significant events others recorded routine information. The regional manager, who was present for part of the inspection, confirmed the expectation that only significant events be recorded in this record. The ‘acting’ manager confirmed this would be discussed at team meetings. She intended to request PCP facilitators to reinforce correct record keeping practices. She expressed the view that the new record keeping system, which was imminently due to be implemented would resolve this problem. Discussion took place between the inspector and management on the staffing needs of the service user whose care was tracked. Though his care plan specified additional staffing ratios of 2:1 when out in the community this conflicted with information from care management. The inspector referred management to the source of this information in which it was clearly specified he received 1:1 staff support in the home to meet his mobility needs. This was not provided at the time of the inspection and it was asserted by the ‘acting’ manager not to be necessary. An occupational therapy assessment on his file dated 2002 reported that he experienced difficulty in getting out of the bath due to motor – sensory problems. This was not referenced in his care plan or moving and handling risk assessment. Staff accommodating the wishes of this individual to take several baths a day at the time of the inspection made no reference to difficulties with access to the bath. It was noted that he used a wheelchair when out in the community. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 15 The regional manager was requested by the inspector to ensure a record was maintained in the home of any additional contracted hours for named service users. This was important to enable judgements by inspectors on the adequacy of staffing levels. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 16 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. Further ways must be explored to increase opportunities for service users to make choices in their daily lives. Also to be enables to integrate in their local community in accordance with assessed needs and individual plans. Service users receive a healthy diet though attention is necessary to individual dietary needs to ensure these are met. The practice of staff assisting service users with meals could be further improved. EVIDENCE: Individual staff interacted with service users in a friendly and respectful manner. Others were observed to be less motivated to talk with service users or take advantage of opportunities to engage them in constructive activities. Examples of this were staff supporting service users with lunch in the dining room in silence. They stood over service users whilst assisting them with food and drinks without verbal prompting or words of encouragement. On another occasion a member of staff with delegated 1:1 responsibility for supporting a service user in the lounge was noted to be reading a newspaper and not engaging with this individual. Staff did not involve service users in domestic Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 17 tasks in the presence of the inspector and did not describe doing so as standard practice. It was stated they were planning to involve service users in cooking and other domestic activities. One staff member expressed the wish to involve a service user in baking cakes but stated the key worker system was an obstacle. In discussion with the ‘acting’ manager it was acknowledged that some staff were not clear of the key worker role and this created tension between staff members. Revised activity plans were being prepared for each service user and aggregated plans for the whole service. The ‘acting’ manager was optimistic that the activity plans being devised to underpin the ‘active support’ model of practice would address these problems. The team was receiving training delivered by the organisation’s behaviour specialist manager. This was designed to enable staff’s understanding of the fundamental principles and practice of the model of care termed ‘active support’. A number of staff were attending this training session at the time of the inspection. Other training in recent weeks in preparation for changes in practice had focused on challenging behaviours, norms and values. In the activity plans available it was evident that opportunities had recently increased for service users to go out in the community with support workers. Examples of this were the involvement of a service user in purchasing his tobacco at a local supermarket. Another service user enjoyed frequent visits to a local garden centre. There he had purchased a plant that he kept in his bedroom. Staff prompted him to remember to water it and this gave him a special interest. The ‘acting’ manager was optimistic that service users had further potential for individual growth and development. She expressed her opinion that they could benefit from increased time and opportunity for learning and using practical life skills. Contact with three staff members, which included a senior support worker, confirmed positive attitudes towards proposed changes to working practices. They acknowledged a more proactive approach was necessary to enable service users to engage in age appropriate suitable activities, inside and outside of the house. The ‘acting’ manager referred to the possibility of adjusting some shift patterns for staff. This would allow one staff member to work across both day shifts to the benefit of activity programmes. The profound learning disabilities and challenging behaviours of the service users inhibit opportunities for employment or to attend further education classes at colleges. Staff from Surrey Oaklands NHS Trust continued in the provision of 30 hours a week day care for six of the seven service users. The inspector was informed that support workers also engaged at times in the structured, individualised day care programme produced by Surrey Oaklands day services staff. On the day of the inspection day these staff supplemented Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 18 the home’s staffing levels during peak periods by prior agreement. This compensated for a staffing shortfall whilst staff attended a training course. Positive relationships between day services staff and the home’s management and staff was evident. Three service users later went out with day services staff on a trip to the seaside where they enjoyed walking by the sea and a take away of fish and chips. The home had recently received a replacement mini bus, which had access for wheelchair users. There were four approved staff drivers on the staff team. Risk assessments had been carried out to ensure safety when transporting service users. Records and discussions with staff confirmed effort made to facilitate and promote family links. Comment cards received from two relatives/visitors confirmed their experiences of being made welcome by staff when they visited. They were also afforded opportunities for privacy. Support workers had generic roles, which included responsibility for cleaning and catering duties. The ‘acting’ manager said that staff had recently begun to engage service users more in shopping for food. Whilst the home had a budget for a cook this post had not been filled. The regional manager expressed preference for support workers to undertake catering duties as part of their role rather than the employment of dedicated catering staff. At the time of the last inspection, feedback from staff was that they considered staffing levels to be inadequate. They expressed opinion that catering duties detracted from care hours. Whilst staff did not on this occasion suggest staffing levels were inadequate it remains an outstanding requirement from the last inspection for a staffing review to be undertaken. It is important as part of the review to take into account non-contact time spent by staff on ancillary duties. The menus had been recently reviewed and a four weekly rotating menu was operating. Discussed was for consideration to be given to the benefits of provision of pictorial menus. Whilst a choice of main meals was not recorded on the menu, in practice choice was offered. The inspector observed a service user given pasta as an alternative to the evening meal as he was known to enjoy this. The pasta was left over from lunch and had been stored correctly. The importance of maintaining records of all meal substitutions was discussed. This is necessary to monitor and assess that individuals receive a balanced, varied and nutritional diet. Observations identified that staff were not adhering to the special medical, religious and cultural dietary needs of a service user. The meals served on the day of the inspection were substantial and nicely presented. Fridge & freezer temperature records were satisfactorily maintained but food probing temperature records could not be found. The ‘acting’ manager could consider making provision of two dining tables to enable staff to sit with service users when assisting them at mealtimes. Staff did not eat at the same time as service users. Staff explained this had not worked when tried in the past on account of the amount of attention and support needed by service Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 19 users. An occupational therapy assessment was awaited for a service user to assess needs for special equipment to aid eating skills. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 20 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. The health care needs of service users were met through primary and specialist health services. A named community nurse has formal links with the home. The G.P. was responsive and took interest in the health and welfare of service users. The community team for people with learning disabilities was also actively involved in meeting needs and supported the team. EVIDENCE: There were concerns for the health & safety of support workers when bathing a named service user without provision of a hoist. This individual’s need could no longer be met and arrangements were being made for an alternative placement. The ‘acting’ manager confirmed that in the interim she was urgently seeking another assessment by a physiotherapist. It was intended to make provision of any equipment necessary to ensure safe practice. Service users were registered with a general practitioner (GP) who was stated to take an active interest in the health of service users. He visited the home routinely every two weeks. Service users had access to specialist and psychiatric services and para medical advice and support. The ‘acting’ manager confirmed that health care action plans were being further developed as part of Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 21 the person centred plans being implemented. On the file sampled it was noted that as part of the existing care plans a health care action plan had been formulated though not fully implemented. It was noted but not clearly explained by record keeping that this individual had not had a flu injection though part of his plan; also the advice of the dietician was not fully adhered to in relation to the content of his diet and monthly weight monitoring practices. Service users dis not have access to ‘well man’ services. The ‘acting’ manager confirmed she was in discussion with the home’s GP in this matter. Service users continued to receive opthalmic and chiropody services and dental care from a specialist dental service. A protocol was in place for the management of multiple seizures for a service user who has a history of seizures that can be life threatening. This was produced following the last inspection and stated to be again under review in consultation with the GP. PRN rectal medication used for responding to related critical incidents was stored securely in the home and a record maintained. This included details of the expiry date of this drug. The policy of the home was to summon paramedics in the event of multiple siezures taking place in accordance with a written protocol. A recent related incident highlighted the need for improvement in incident record keeping to enable oncall managers to make informed decisions about contact with emergency services. Observations confirmed the need for improvement in the storage of personal toiletries and toothbrushes to ensure adequately hygenic. A senior support worker had delegated responsibility for the management of medication. Medication was stored in a metal medicine cupboard in the ground floor sensory room. A monitored dosage system (blister packs) was operating. The organisation’s medication policy and procedure was satisfactory and kept in the office. Staff with delegated responsibility for medication administration had received suitable theoretical training also practice assessments carried out. A record of the signatures of all but one of these staff was maintained. A number of staff were not approved to administer medication as their practice assessments remained outstanding. This was drawn to the attention of the ‘acting’ manager who was a trained ‘assessor’ at the time of the inspection. She confirmed her intention to complete these practice assessments. Medication was checked by staff at the time of receipt and records were maintained of receipt and disposal of medicines. PRN medication had been ommitted this month from MARR charts which was an oversight by the pharmacist. The senior support worker confirmed he would contact the pharmacy in this matter. PRN medication was stored securely in individualised wallets which were sealed with numbered tags. System for administration of PRN medication were satisfactory and underpinned by written protocols. These were last reviewed in 2004 and stated to be currently being reviewed by the behaviour specialist manager in consultation with the GP. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 22 Mostly medication administration was signed for there though some gaps of signatures in record keeping were found. The practice of secondary dispensing of medication given to relatives when a service user goes on leave was not acceptable. This required review and a suitable alternative system found. As part of the implementation of person centred plans wishes were being sought from relatives in respect of the ageing, illness and death of service users. This information was not detailed in a suitable care plan in the care documents sampled. The inspector would have appreciated suggestions and guidance from staff on ways to illicit and interpret information when communicating with service users during the inspection. Whilst it is acknowledged that self-portraits records held in the office contain this information it is suggested that staff brief visitors with ways of communicating with service users that they are able and willing to use. It would have been helpful if communication ’tools’ and guidance had been offered covering trigger words or areas of obsessive interest to be avoided. Also verbal guidance covering significant personal safety issues when in contact with service users. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 23 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. Complaint procedures were in place and had been issued to service users relatives. Attention was required to the recording and storage of complaint records. Robust procedures for responding to suspicions or allegations of abuse were also in place. Improvement was necessary in practices relating to service users personal money. EVIDENCE: The complaint procedure was available in various formats including symbols and pictorial form. Service users did not have independent advocacy. The ‘acting’ manager described discussions at staff meetings in which staff needed to further consider service users rights and choices. Also to ensure service users’ voice in decisions by staff directly affecting them, however well intentioned. Whilst no complaints were recorded in the home’s complaint record it was known from Regulation 37 notifications to the CSCI that at least one compaint had been investigated by management. The need to record all complaints in appropriate records was discussed. The book used for this purpose did not include all relevant information. Also issues relating to third party witness confidentiality needs consideration in the accessibility of these records. The complaint procedure was stated to have been reissued to relatives since the last inspection. Safeguarding vulnerable adult procedures were in place produced by the organisation. An up to date copy of local multi-agency safeguarding vulnerable adults procedures needs to be obtained. It was suggested to the ‘acting’ manager that the home obtains also a copy of the Department of Health’s Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 24 revised guidance on the POVA Scheme. Whistleblowing procedure were available and included in new handbook issued to all staff. This cross referred to a telephone directory which contained telephone numbers for external managers and of other relevant agencies. All staff had received adult protection awareness training as part of their induction. With the exception of four support workers, staff had attended adult protection training sessions in the past. Refresher adult protection training was stated to be arranged for the whole team. Recruitment procedures safeguarded service users. Since the last inspection whistleblowing procedures had been used for making a number of serious allegations of financial abuse and physical abuse/poor practice. These allegations were subject to ongoing investigation under Surrey’s multi-agency safeguarding vulnerable adults procedures. The findings to date had identified the need for significant improvement in the home’s managements and standards of practice. An action plan was in place for improvement in service provision. The home’s financial record keeping practices were not in accordance with organisation’s policy and procedures. Service users had individual books with accounting entries on unnumbered pages dating back to 2002. This practice was open to the potential for records to be altered. The Avenues procedures provide monthly individual accounting records which had not been implemented. The ‘acting’ manager confirmed she was not a signatory to enable her to withdraw money from service users building society accounts on their behalf. Action had not yet been taken for the ‘acting’ manager to become a signatory and this situation was likely to cause significant problems if not resolved shortly. Other signatories were the home manager who was on long term leave, the last registered manager who had not worked for this organisation for three years and a senior support worker who was working out her notice. The ‘acting’ manager’s attention was also drawn to the organisations policy which clearly stated that signatories for service users money should be service managers, managers or senior house managers. The ‘acting’ manager stated it was essential for senior support workers to be signatories and planned to discuss this policy with her line manager. Observations identified the routine practice of exceeding the maximum amount of money on hand without good reason for a number of service users. This was outside the organisations policy. Money withdrawels were adhoc and evidently required closer monitoring by management. Also improvement in financial record keeping was necessary to ensure staff countersigned entries in financial records. Systems were in place for checking money on change over of shifts. The inspector identified small discrepencies on checking financial balances of two service users. Observations also highlighted the need to formalise and record authorisation from the service manager for withdrawal of service users’ money exceeding the specified amounts referred to the organisation’s financial policy. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 25 Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 26 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is POOR. This judgement has been made using available evidence including a visit to this service. The physical environment of the home matched the needs of service users for whom the home was intended in accordance with the statement of purpose. Attention was required to maintenance of the grounds, the standard of décor in some areas and furnishings and to odour control. EVIDENCE: The home is well situated in terms of neighbouring properties to avoid noise nuisance yet close to shops and other community amenities. Support workers’ roles are generic. They are responsible for maintaining standards of cleanliness and for laundry tasks. They undertake minor maintenance work and in the past, maintenance of the garden. The decoration of the exterior of the home appeared satisfactory and the grounds were secure. The ‘acting’ manager and other staff demonstrated understanding of the importance of provision of a low arousal environment to reduce stress levels for service users. The ‘acting’ manager was considering further ways for creating a more ‘homely’ environment and for supporting service users in personalising bedrooms. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 27 It was noted that the lounge had been redecorated in a neutral colour scheme since the last inspection. New curtains, wind chimes and some pictures had been successfully introduced in this area. Further redecoration was intended in parts of the home. This was planned in the dining room where walls also needed repair. The hazardous floor covering in the first floor bathroom was imminently due to be replaced. A toilet seat was also required in the ground floor bathroom. At the time of the inspection there were no paper handtowels in holders in bathrooms and toilets and no soap in the soap dispensers. The ‘acting’ manager confirmed new, more suitable handtowel holders, toilet roll holders and soap dispensers were on order. Some bedrooms needed redecoration as colour schemes were vivid and clashed and probably were unsuited to the needs of service users. Carpets/floor covering in areas of the home also required replacement also some bedroom furniture. The settees in the lounge were in need of replacement and suitable curtains or blinds provided in bedrooms. The washbasin in the kitchen also needed to be resealed. Consideration could be given to provision of additional signs, symbols and photographs in the environment to further aid communication. The ‘acting’ manager stated there was a maintenance and renewal programme in place. She did not have a copy of the same however and was not informed of timescales for work to be undertaken. The organisation had contacted the landlord for the premises to clarify responsibilities for the maintenance of the building. The ‘acting’ manager stated there were plans to recruit a local handyperson to carry out maintenance work. Repairs were carried out by Surrey Oaklands NHS staff who staff said responded promptly to notifications of work where health and safety risk were present. The garden was very overgrown and the regional manager stated there were plans for this to imminently receive attention. The home had a sit on mower which was not currently functioning. Staff had recently cleared the garden shed and the ‘acting’ manager stated it was intended to use the shed in the summer for activities. Discussed was the need to purchase suitable sun shade for the garden. Also to make provision of staff lockers if the current facility used to safe storage of their possessions is used for another purpose as intended. The ‘acting’ manager expressed the wish to use the lounge area next to office on first floor as a quiet room. This would enhance the home’s facilities providing an area for service users to meet visitors in private. Currently it is used by staff for meetings and training which would continue. The ‘acting’ manager was considering using the kitchenette in this room for domestic skills training for service users in the longer term. The home had a sensory room with sensory equipment. Provision included aromatherapy services from an external trained practitioner. She commented in her feedback that staff were welcoming and supportive when she visited. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 28 At the time of this inspection an unpleasant odour of urine was present on the first floor corridor. Support workers advised this was due to behaviours of service users who urinated in this corridor. It was not clarified what action was taking place to address this behaviour. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 29 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36 Quality in this outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. Staff recruitment and vetting procedures protected service users. The need to maintain statutory ID documentation and CRB records for staff in the home was an outstanding requirement. A relevant staff induction and training programme was in place. The home did not employ 50 of support workers with care NVQ level 2 or equivalent qualifications. Staffing levels appeared adequate at the time of the inspection visit. EVIDENCE: The staff - training programme included training to support understanding of positive communication, autism, mental health disorders and challenging behaviours. This was additional to all statutory training and other service specific training, for example, epilepsy. The staff training records confirmed that the majority of staff had undertaken extensive relevant internal training. Recent training for staff included ‘active support’ and ‘challenging behaviours, norms and values’. A development plan included proposals for team building. Regular staff meetings were stated to take place though the last team meeting minutes were for a meeting convened in January 2006. The ‘acting’ manager currently was using administrative/typing services based at head office and was waiting for minutes of more recent meetings to be typed and returned. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 30 Current staffing levels during the day were 6 support workers on the early shift and 5 on the late shift and 3 waking night staff excluding the manager. One service users was receiving a ratio of 1:1 staffing throughout the 24 hour period and another received 1:1 staffing 10 hours daily. A number of service users were assessed to require 2:1 staffing levels when out in the community. At the time of the inspection records were being maintained of night activity and examined. These confirmed that individual service users were very active for most of the night hours. The ‘acting’ manager confirmed that a review of staffing needs was currently in progress. It was noted that there had been only one staff change since the last inspection of a senior support worker who had transferred to another home. He was noted to be imminently due to return to Chelsham Lodge. A senior support worker was working out her notice at the time of this inspection and another was on long term leave. A part time senior support worker worked weekends only. The ‘acting’ manager stated she would like to recruit a senior support worker for night duty in the future. Discussions with a senior support worker suggested that staff morale had been poor in recent times but that this was gradually improving. This was attributed to the passage of time since allegations were made which had caused staff to be suspicious of each other and divisions in the team. It was stated that staff were positive about recent input of agency staff already known to the home. They had known service users and this reduced pressure on other staff’s time. Though some staff were considering or were leaving new staff recently appointed and due to take up post were also known to the team and were liked and respected. In following up requirements for personnel documentation to be held at the home, it was noted that the ‘acting’ manager was still collating this information. Also that a CRB record for the home had not been compiled. The ‘acting’ manager stated that the supervision of staff was now up to date. This had lapsed and had not be carried out prior to this since November 2005. There were plans for supervision responsibilities to be delegated to senior support workers with any support needed; also for supervision sessions to be scheduled to be carried out on a more regular basis. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 31 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 Quality in this outcome area is ADEQUATE. This judgement has been made using available evidence including a visit to this service. A competent and experienced manager was managing the home in an ‘acting’ capacity. There was evidence of effective and improved quality assurance systems. Also good progress in implementing an improvement plan produced to address deficiencies and raise standards in the home’s management and operation. A significant number of health and safety issues required attention. EVIDENCE: The ‘acting’ manager was registered with the CSCI for the management of another care home operated by the Avenues Trust. She had taken over the management of Chelsham Lodge in February 2006 following unplanned leave of absence of the home manager. The ‘acting’ manager possessed relevant qualifications, knowledge and experience to manage the home and provide leadership and direction to staff. She had attained the Registered Managers Award (RMA) and was studying for NVQ Level 4 qualification in management of care. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 32 At the time of the inspection there were four full time and one part time senior support workers in post, two of whom were on leave of absence and one working out her notice. One senior support worker also had attained the RMA qualification. The two senior support workers present on the day of the inspection were credited by the regional manager and ‘acting’ manager for their hard work over recent months in managing the significant challenges and change. They had ensured continuity of care and services during the absence of the home manager whilst the home was under investigation and during the orientatio period for the ‘acting’ manager. Management was mindful of the need to provide both senior support workers with support and ensure adequate time off. It was noted that one senior support worker who had assumed additional responsibilities now had two supernumary days to enable him to attend to administrative work. This employee reported being under significant workload pressures initially whilst the ‘acting’ manager was taking over the home. He was enthusiastic regarding the changes planned and felt involved in the development of the home’s improvement plan. The ‘acting’ manager was perceived to be coping well with the challenges; also to be making progress in introducing changes in practice and implementing the development plan for improvement and monitoring service users progress. This timetable for change included changes in working practices, introducing person centred planning and a skills and team building programme. She confirmed she received good support from her line manager and other managers within the organisation; also good external professional support from other agencies. Recently all staff received opportunity to express their views about the service and make recommendations. It was reported in the last provider report that staff had been positive about the direction and leadership provided to the team by the ‘acting’ manager. The ‘acting’ manager expressed confidence in the abilities of the team to raise standards and stated individual senior support workers were cooperative and committed to changes for improvement. She referred to discussions within the organisation on the intention to have deputy manager post within the management structure of care homes in the future. She regarded this as a positive proposal. The ‘acting’ manager acknowledged there was still much to be done for raising standards at the home. An urgent need for admin support including typing support had been recognised by senior management. Action was being taken to arrange 12 hours agency administration support. Quality assurance and monitoring systems had improved since the time of the last inspection. Service managers were directed to spend at least 80 of their time visiting care homes in accordance with a policy decision. Monthly provider visits focusing on outcomes for service users were structured by national minimum standards. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 33 A new development had been the monthly provision of incident data analysis for homes. The organisation’s quality assurance department provided this. For the past 18 months this department had been focusing on the implementation of person centred planning in care homes, providing input, support and training as necessary to staff teams. Quality auditing systems were in evidence. An annual survey of the views of relatives/advocates was also carried out. Corporate policies and procedures were held centrally in the office. The ‘acting’ manager stated new and revised policies and procedures were drawn to the attention of staff. She confirmed the future intention for supervision sessions to be used to confirm staff’s awareness of new policies and procedures and understanding of all policies and procedures. New policy files were imminently due to be implemented. Staff also had personal handbooks containing key policies. The home’s registration certificate and a current certificate of insurance were displayed. The inspector met with the senior support worker with delegated lead responsibility for health and safety and maintenance matters. Observations confirmed various risk assessments in place and regular audits carried out. He was requested to carry out a risk assessment of hazards in the garden. Areas for attention were loose light switches and electrical sockets and the need for portable electric appliance testing to be carried out which was due. It is acknowledged action was being taken in both matters. COSHH risk assessments were examined and management was aware of the need to produce COSHH data sheets for individual hazardous products. Support workers had received foundation training in food hygiene and confirmation of this training for agency staff was being sought. The fire risk assessment had been reviewed and further developed since the last inspection. However individual care plans to address risks identified by the fire risk assessment remained outstanding. The inspector was informed that a bedroom door held open with by a magnetic holder, which was integrated into the fire detection system, was faulty. This did not automatically close when the fire alarm sounded. Requirement was made for this to be included in the fire risk assessment and the fire procedures to minimise this risk. Also for the home’s fire safety contractor to be requested to carry out remedial work to the magnetic holder. A first aid training programme for staff was noted. The home had two qualified first aider’s who had attended a 4-day first aid training course entitled ‘appointed person first aid training’. Other staff had received basic first aid training, which included cardiopulmonary resuscitation. Provision was made of first aid boxes in the home. The inspector examined maintenance and service records, which were found to be satisfactory. The electrical wiring certificate could not be located so it was not possible to establish if this was current. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 34 Requirements included the need to reseal the washbasin in the kitchen and ensure locked storage of cleaning materials under the kitchen sink. Also to ensure creams, toiletries and shavers are stored safely in bedrooms. Additionally for improvement in the storage on toiletries and toothbrushes to ensure adequate hygiene. Action must be taken to ensure safe practice when moving & handling a named service user in the bathroom. Suitable hand washing materials must be provided in bathrooms and toilets to promote good hygiene practices. Paints and white spirit bottles should be relocated from the kitchenette on the first floor and securely stored. The need to undertake food probing and to maintain records was discussed. Risk assessments were in place for two service user who are smokers. One service user was permitted to smoke his pipe under supervision in his bedroom. Discussed was the need to also consider any health and safety implications of passive smoking for staff supporting this individual in this activity. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 35 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 1 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 3 26 2 27 1 28 3 29 1 30 1 STAFFING Standard No Score 31 x 32 1 33 2 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 2 2 X LIFESTYLES Standard No Score 11 2 12 X 13 2 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 x 2 3 2 1 x Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 36 Are there any outstanding requirements from the last inspection? Yes 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. Standard 1. YA1 Regulation 4(2) 6 (b) Requirement For the Registered Person to ensure that the Statement of Purpose and Service Users Guide is updated and copied to the CSCI. The timescale for compliance with this requirement was unmet from the last inspection. For the Registered Person to ensure provision of appropriate communication aids and cues in the home environment suitable to meet individual needs. For the Registered Person to ensure care plans and care practice demonstrate commitment to and celebration of equality and diversity. For the Registered Person to ensure care plans are further developed to detail how service users assessed needs are to be met. Additionally for care plans and risk assessments to be regularly reviewed, at least six monthly. For the Registered Person to ensure a person –centred philosophy underpins the home’s operation and care practices. There is a need to increase opportunities for the personal growth and development of individual service users, engaging them, where possible, in domestic DS0000013595.V292882.R01.S.doc Timescale for action 22/07/06 2. YA3 12(1) (a)(b) 22/08/06 3. YA6 15(1) 22/06/06 4. YA6 14(2) (a)(b) 15(2) (b) 22/06/06 5. YA11 12(1) (a)(b) 16(2) (m)(n) 22/08/06 Chelsham Lodge Version 5.1 Page 37 routines. 6. YA17 17(2) Sch4 (13) For the Registered Person to ensure records are maintained of substituted menu options and of food consumed which differs from the menu to afford choice and meet special dietary requirements. For the Registered Person to ensure review of care practice in the dining room. For the Registered Person to ensure the weight of a named service user is monitored monthly in accordance with specialist advice. Also for a care plan to be produced for this individual clearly specifying his medical, cultural and religious dietary needs and be taken into account in menu planning and catering practices. For the Registered Person to ensure improvement to the storage of toiletries and toothbrushes to promote hygienic practices. For the Registered Person to ensure review of the current practice of secondary dispensing of medication. For the Registered Person to ensure PRN medication is included on MARR charts. For the Registered Person to ensure that medication administration records are signed. For the Registered Person to ensure safe storage of prescribed lotions and creams for topical application. For the Registered Person to ensure records are maintained of all complaints, also for complaint record keeping practices to safeguard third party/witness confidentially. For the Registered Person to ensure all staff receive adult protection training. The timescale for compliance with this requirement is unmet from the last inspection. DS0000013595.V292882.R01.S.doc 29/05/06 7. 8. YA17 YA19 12(1) (a)(b) 12(1) (a), 12(4) (b) 22/06/06 29/05/06 9. YA19 13(3) 29/05/06 10. 11. 12. 13. 14. YA20 YA20 YA20 YA20 YA22 13(2) 17(1) (a) Sch3 3. (i) 17(1) (a) Sch3. 3(i) 13(4) (a)(b) (c) 17(2) Sch4 (11) 29/05/06 23/05/06 23/05/06 22/05/06 23/05/06 15. YA23 13(6), 18(1) (a)(c) (i) 22/06/06 Chelsham Lodge Version 5.1 Page 38 16. YA23 10(1), 12(1) 17. YA24 YA26 23(2) (d) 18. 19. 20. 21. 22. YA24 YA24 YA24 YA24 YA24 23(2) (b)(o) 23(2) (b) 23(3) (a)(ii) 23(2) (b) 16(2) (c) For the Registered Person to ensure improvement in financial record keeping and practices relating to service users personal money which is currently not in adherence with the organisation’s own procedures. There is a need to ensure appropriate levels of withdrawals from service users accounts in compliance with procedures. A record should be maintained also of the service manager’s authorisation of withdrawals from service users accounts exceeding the amount specified in the organisation’s policy. Staff should also ensure the practice of countersigning financial records relating to withdrawals and expenditure. For the Registered Person to ensure redecoration and refurbishment of bedrooms discussed, also replacement of floor covering and redecoration of the dining room. For the Registered Person to ensure adequate arrangements in place for garden maintenance. For the Registered Person to ensure the wash hand basin in the kitchen is resealed. For the Registered Person to ensure staff have suitable facilities to secure personal effects. For the Registered Person to ensure the missing toilet seat in the ground floor bathroom is replaced. For the Registered Person to ensure windows in bedrooms to have suitable blinds or curtains. An assessment of the needs of service users in bedrooms supplied only with net curtains must be carried out. The timescale for compliance with this requirement is unmet from the last inspection. 22/06/06 22/08/06 22/06/06 22/08/06 22/08/06 29/05/06 22/08/06 Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 39 23. YA24 10(1) (a) 23 (2)(b) For the Registered Person to ensure clarity of responsibilities for maintenance of the premises between the landlord and registered organisation. Timescale for compliance unmet however it is acknowledged this is in progress. For the Registered Person to ensure adequate aids and safe moving and handling practices for bathing a named service user, pending his discharge. For the Registered Person to ensure the unpleasant odour of urine in the corridor on the first floor is eradicated. For the Registered Person to ensure that 50 of support workers (including agency staff) have NVQ Level 2 qualifications or equivalent. Proposals for compliance to be forwarded to the CSCI. For the Registered Person to review the adequacy of day staffing levels to ensure delivery of safe and appropriate care and support. The outcome of this review must be communicated to the CSCI. Timescale for compliance unmet from the last inspection however it is acknowledged action for compliance is currently in progress. For the Registered Person to ensure a record is maintained at the home of any contracted additional hours funded by purchasers for named service users. For the Registered Person to ensure personnel records held in the home include a recent photograph of staff; also proof of identity and documentary evidence of relevant qualification and training at the time of appointment. Timescale for compliance unmet from the last DS0000013595.V292882.R01.S.doc 22/08/06 24. YA27YA4 2 23(2) (n) 29/05/06 25. YA30 16(2) (k) 18(1) (a) 22/06/06 26. 22/08/06 27. YA33 12(1) 13(4) (c) 18(1) 22/07/06 28. YA33 17(2) Sch4.8 22/07/06 29. YA34 17(3) (b) Sch 2 22/07/06 Chelsham Lodge Version 5.1 Page 40 inspection however it is acknowledged action for compliance is now in progress. 30. YA34 19 Sch 2.7 For the Registered Person to ensure a central record is maintained in the home of all Criminal Record Bureau Disclosures for the staff team in accordance with CRB policy guidance. Timescale for compliance unmet from the last inspection. For the Registered Person to ensure review of the home’s fire procedures to ensure interim safety measures are in place to address the problem of failure of a bedroom door closure to automatically release when the fire alarm is activated. For the Registered Person to ensure records are maintained of food probing temperatures. For the Registered Person to ensure the bedroom door fitted with a magnetic holder automatically closes when the fire alarm is activated. For the Registered Person to ensure provision of soap dispensers and disposable towels in all bathrooms and toilets. For the Registered Person to ensure the secure storage of COSHH substances in the kitchen. For the Registered Person to ensure the first floor bathroom floor covering is replaced. For the Registered Person to ensure paint and turpentine stored in the kitchenette adjacent to the office is removed and stored securely in a suitable secure facility. For the Registered Person to ensure the home’s health and safety risk assessments includes regular audits of the storage of toiletries to ensure safety and hygiene. Also regular inspection of environmental hazards in the grounds. DS0000013595.V292882.R01.S.doc 22/07/06 31. YA42 23(4) (c)(i) 23/05/06 32 33. YA42 YA42 13(4) (c) 23(4) (c)(i) 23/05/06 29/05/06 34. YA42 13(3) 23/05/06 35. 36. 37. YA42 YA42 YA42 13(4) (a)(b) (c) 23(2) (b) 13(4) 22/05/06 22/06/06 29/05/06 38. YA42 13(3) (4) 23(2) (o) 29/05/06 Chelsham Lodge Version 5.1 Page 41 39. 40. 41. 42. YA42 YA42 YA42 YA42 12(1) (a), 13(4) (c) 18(1) (c)(i) 23(2) (c) 23(2) (b), (4) 43. YA42 10(1), 13(5) 44. YA42 13(4) (c) 23 (4) For the Registered Person to ensure provision is made of suitable sunshade in the garden. For the Registered Person to ensure COSHH data sheets are produced. For the Registered Person to ensure portable electrical appliance testing is carried out. For the Registered Person to ensure the home has a current electrical certificate for hard wiring. A copy of this evidence to be forwarded to the CSCI. For the Registered Person to ensure health and safety risk assessments include risks relating to passive smoking when supporting a service user in this activity in his bedroom. For the Registered Person to ensure fire safety risks identified in the fire risk assessment generate care plans to manage these risks for named service users. The timescale for compliance with this requirement is unmet from the last inspection. 22/06/06 22/06/06 22/06/06 22/06/06 22/06/06 22/06/06 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 YA23 YA26 YA27 YA28 Good Practice Recommendations For the Registered Person to ensure the home has a copy of the revised local multi-agency safeguarding vulnerable adults procedures available for reference. For the Registered Person to replace the settees in the lounge. For the Registered Person to create a more domestic environment in bathrooms which are currently clinical in appearance. For the Registered Person to replace the large dining table with two tables in the dining room to provide room for staff sit with service users when supporting them with DS0000013595.V292882.R01.S.doc Version 5.1 Page 42 Chelsham Lodge 5 6 YA33 YA41 meals. For the Registered Person to provide further training for key workers and ensure they and all staff are clear regarding the key worker roles and responsibilities. For the Registered Person to review record keeping policies and practice in the completion of ‘daily logs’ to ensure consistency. Chelsham Lodge DS0000013595.V292882.R01.S.doc Version 5.1 Page 43 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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