Inspection on 26/07/05 for Chelsham Lodge

This inspection was carried out on 26th July 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 no outstanding requirements from the previous inspection report, but made 2 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 22/05/06

Chelsham Lodge 08/11/05

Chelsham Lodge 14/12/04

Chelsham Lodge 03/08/04

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Southfields

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Dovedale Court

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

CARE HOME ADULTS 18-65 Chelsham Lodge High Lane, Warlingham, Surrey, CR6 9DQ Lead Inspector Fiona Cole Unannounced 26 July 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chelsham Lodge Address Chelsham Lodge, High Lane, Warlingham, Surrey, CR6 9DQ 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) 01883 622168 The Avenues Trust Limited Mr Ira Thomas CRH Care Home 7 Category(ies) of LD Learning disability, 7 registration, with number of places Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The` age range of service users is: 37 - 60 YEARS Date of last inspection 14-December-2004 Brief Description of the Service: Chelsham Lodge is a large detached property, owned and operated by the Avenues Trust, to provide care for younger adults with learning difficulties. The house is situated in the village of Warlingham, between Caterham and Croydon, with local pubs, shops, churches and a school nearby. All service users have single bedroom accommodation and have access to all communal areas, including a large lounge, dining room and sensory room. The laundry and kitchen area can only be accessed with staff support. The home has four bathrooms, with one bathroom offering walk-in shower facilities. The home has a number of small mini buses for transporting service users on outings, and there is plentiful parking to the side of the house. The home has a large secure garden with a surrounding fence and hedge. There is a paved patio with garden furniture and sufficient shaded areas for the service users. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the homes first inspection for the year 2005/2006. This was an unannounced visit, which meant staff and service users were unaware it was to take place. The inspection began at 10am and was satisfactorily completed at 3.30pm. A senior support worker acting in the manager’s absence, competently carried out the most part of the inspection, the manager was present for the last hour and a half. The first part of the inspection was spent checking previous requirements from the last inspection report had been met. The inspector then, had a guided tour of the home and the grounds, paying particular attention to the environmental issues raised in the last inspection report. The inspector spoke with 2 service users and 4 members of staff during the tour, giving the inspector the opportunity to make sure there were no ongoing problems with the running of the home and that any issues that the home faced previously were being addressed. The second part of the inspection was spent observing staff working with service users and checking records. What the service does well: The home has a committed and experienced group of staff that have a good and sound knowledge of the service users needs. They are keen to improve the quality of life of the service users by offering them a varied programme of activities despite their profound disabilities. The medication recording was of a good standard and all staff have now been trained to administer the medication in line with Royal Pharmaceuticals Societies guidance. Staff files were comprehensively completed and showed attendance at a number of training courses, and refresher training. Two staff members who spoke with the inspector had a thorough understanding of how they would deal Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 6 with a vulnerable adults situation, and demonstrated their knowledge of the Surrey Vulnerable Adults Multi Agency Procedures. Staff were observed to be friendly and caring towards the service users encouraging and supporting them to be as independent as possible and involving them in daily household tasks where appropriate. What has improved since the last inspection? What they could do better: An upstairs and a downstairs bathroom still require further work to ensure they are fully serviceable. Repairs to the woodwork are still outstanding, where it is rotting around the sink and toilet areas. Grouting is old and needs replacing. The downstairs bathroom had a cracked ceiling where water has penetrated through from the upstairs toilet. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 7 An assessment of night staffing quotas needs to take place to ensure there is adequate cover for all service users between the hours of 930pm and 730am. The registration certificate must be displayed at all times. 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 H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 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 standard(s) 1 2 The home was found to be operating effectively in respect of these standards. The inspector was impressed by the availability and quality of the information about the home and felt confident that any prospective service user with the help of their family or representative would be able to make an informed choice as to whether the home would be a suitable place to live. EVIDENCE: The home has recently reviewed and revised its statement of purpose and service user guide; these have been made more user friendly and now have pictorial representations. Sampling of care plans showed the home has a sound process of assessing service users needs and wishes, and this was being further enhanced by the implementation of person centred planning. This is still in progress. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 10 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 standard(s) 6 7 8 9 10. Evidence gathered from this inspection showed that each of these standards are being met effectively. This gives confidence that each individuals needs and wishes are being recognised, and met. EVIDENCE: Service users were unaware that care plans were in place, but they had effectively contributed to parts of the process using picture symbols as a method of communication, particularly on the body charts, shown to the inspector. Daily diary notes and discussions with staff provided evidence that service users were encouraged to be as independent as possible where appropriate. It was evident that risk assessments were produced with the individual as far as possible and any restrictions applied if the level of risk was considered unacceptable. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 11 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 standard(s) 11 14 16 The home meets each of these assessed standards. This means the home was able to demonstrate to the inspector that service users were encouraged and supported to be as independent, and lead as fulfilling lives as they are able. EVIDENCE: The relationships observed by the inspector between staff and service users were relaxed, friendly and reassuring, particularly when one service user became upset and started to shout and bang the furniture. Service users are encouraged to take part in household activities where possible. Some service users are unable to take part in certain activities as the risks are too great. Staff spend time with them in the sensory room or going out for walks in the grounds, the local area, or out on trips in the minibus. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 12 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 standard(s) 18 19 20 The systems in place for Service user consultation are good and access to support from health care agencies is clearly evidenced. The systems for administration of medication are good with clear arrangements in place to ensure that service users medication needs are being met. EVIDENCE: Service users health needs were well met and medication administration was accomplished satisfactorily. The service plans in palce were comprehensive and are reviewed on a monthly basis to ensure they accurately represent service users needs. Daily notes were informative and included details about what activities the service user had participated in and their mental status. Staff stated that service users are involved as much as possible with the care plan development and reviews.. In discussions with staff members the inspector was able to learn how hard the staff have worked to ensure that service users health and personal care needs are consistently met. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 13 There is evidence that service users optical, dental and chiropody needs are met and confirmed in the diary and other records. Where appropriate, occupational therapists, dieticians and speech therapists would be involved in service users care. The records showed assessed medical needs were followed up properly and notes taken of the care given. None of the service users are able to self-administer their own medication and suitably trained staff dispense the medication. All staff are trained in the administration of medication. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 14 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 standard(s) 22 23 Service users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: Some service users did not wish to communicate with the inspector. Observed interactions between service users and staff confirmed the willingness of staff to listen and help in any way they could. There have been no complaints since the last inspection. The home has a detailed complaints procedure in place. All service users have been supplied with a pictorial format. The service has an adult abuse policy in place. Staff have received training in the protection of vulnerable adults in February 2005. The Local Authority multi-agency procedures for protecting vulnerable adults were in place at the service. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 15 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 standard(s) 25 27 28 30 The home meets each of the assessed standards, and provides a reasonable level of accommodation appropriate to the needs of the current service users. EVIDENCE: The location of the home is suitable for its stated purpose; it is accessible, safe and reasonably maintained, meeting service users individual and collective needs in a comfortable way. Standards of cleanliness and hygiene were good throughout the home and no malodours evident. The homes communal areas are spacious and decorated and furnished adequately. No safety hazards were evident within the communal and private space areas. Toilet and bathing facilities were of an acceptable standard and afforded privacy for the service users. Service users bedrooms were decorated and furnished appropriately and had been personalised by the service users. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 33 35 36 Evidence gathered during this inspection confirmed that the home meets each of the assessed standards. Staff on duty appeared to be enthusiastic and committed to supporting service users, with training and development being given a high priority. EVIDENCE: The relationships between staff and service users were observed to be relaxed and friendly. Service users were encouraged and supported to be as independent as possible. Training and development of staff has been given a high priority and this was recognised in the training schedule and staff supervision files. The training programme together with regular supervision sessions undertaken by the manager, showed the commitment to staff training and development, the inspector was impressed with the range of training courses on offer. The staff on duty on the day of inspection were very positive and stated they were keen to learn and gain qualifications. The manager has recently Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 17 completed his Registered Manager’s Award and two senior staff have completed their NVQ4. Three staff have gained NVQ 3 and applications for seven other staff members to undertake their NVQ2 are in place with the local college. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 39 40 42 43 There is good sound leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this through to staff through regular staff meetings and individual supervision sessions. EVIDENCE: The registered manager was able to show that improvements had been made in the further development of the care plans and in the revision and development of policies and procedures. The following records were examined during this inspection: Service Users care plans, service users medication records, staff rota and menus. All of these records were in good order. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 19 Staff were noted to receive training in matters of health and safety and ample information was available to advise staff as to safe practice including lifting and the handling of corrosive materials. There is a detailed health and safety procedure in place. Training and development of staff has been given a high priority and the registered manager has completed his Registered mangers qualification alongside 2 senior staff that have been awarded their NVQ 4 qualifications. Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 N/A N/A N/A Standard No 22 23 ENVIRONMENT Score N/A 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score N/A 3 3 3 N/A Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 2 N/A 3 Standard No 11 12 13 14 15 16 17 2 x x 2 x 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chelsham Lodge Score 3 3 N/A N/A Standard No 37 38 39 40 41 42 43 Score 3 3 N/A 3 3 3 3 H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 21 18(1)(a) YA 33 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 YA33 Regulation 18(1) (a) Requirement The staffing levels at night time must be reviewed to ensure they are adequate to meet service users needs. Rotting wood around sinks and toilets in upstairs and downstairs bathrooms must be replaced/repaired as appropriate. Timescale for action 31/10/05 2. YA24 23(2)9b) 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Chelsham Lodge H09-H58 s13595 Chelsham Lodge v217332 260705 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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