Inspection on 03/10/07 for Chelsham Lodge

This inspection was carried out on 3rd October 2007.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chelsham Lodge 05/12/06

Chelsham Lodge 22/05/06

Chelsham Lodge 08/11/05

Chelsham Lodge 26/07/05

Chelsham Lodge 14/12/04

Chelsham Lodge 03/08/04

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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 High Lane Warlingham Surrey CR6 9DQ Lead Inspector Suzanne Magnier Unannounced Inspection 3rd October 2007 11.30 Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 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.V344604.R01.S.doc Version 5.2 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.V344604.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelsham Lodge Address 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) chelsam.lodge@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Limited To be confirmed Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Male Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 5th December 2006 Brief Description of the Service: Chelsham Lodge is a care home providing personal care for six adults with severe learning disabilities. Individuals may have complex needs and present behaviours, which test service provision. Currently all individuals living at the service are male. The building is a spacious, detached two - storey house situated in a semi-rural location. A large secluded garden is provided. Car parking facilities are available and the home has a wheelchair accessible vehicle. 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. Individuals receive professional specialist input and support. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 5 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. The current weekly fee charges ranged between £ 1784 and £2888. Additional charges are for aromatherapy sessions, toiletries, magazines, cigarettes/tobacco and some social activities. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Ms S Magnier Regulation Inspector carried out the inspection. The home was represented by the newly appointed manager, the deputy manager and in part, the service manager and members of staff. For the purpose of the report the individuals using the service are referred to as people/individuals living in the home. The inspector arrived at the service at 11.30 and was in the home for five and a half hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. Responses to questionnaires that the Commission had sent out and the written comments have been included within the report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, the terms and conditions of residency in the home, care plans, person centred plans, risk assessments, menus, medication procedures, staff files, induction documents, health and safety records and several of the services policies and procedures. Following the previous key inspection in December 2006 the service has met all the requirements made. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspector and comments received, the inspector considers that the home meets the needs of individuals who have diverse religious, racial or cultural needs. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The inspector would like to thank the people living in the home, the staff and the manager for their time, assistance and hospitality during this inspection. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose must be updated to include the home’s current complaints procedure, current details of the manager, the current staffing numbers and training for example staff achievements of the National Vocational Qualification (NVQ). The home must keep the Statement of Purpose and Service Users Guide under review and notify the CSCI and individuals living in the home of any revision within 28 days. Both documents must be made available upon request to any individual living in the home or their representative. A copy must be sent to the Commission for Social Care Inspection (CSCI). All individuals in the home must have an up to date copy of their terms and conditions of stay in the home and the terms and conditions of stay in the home must reflect the current range of fees. The home must revise their menus to include sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition. An overall improvement to the person centred plans has been required that the home must ensure that individuals goals and aspirations are documented in order to give a clear audit and review of the goals they have achieved and what they may wish to achieve. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 8 Further decoration, repairs and hygiene standards need to be implemented including one individual’s bedroom flooring requiring re adhesive or replacement due to wear and tear. Areas in the kitchen, which require cleaning, are the cupboards, surrounding pipe work and the covers of the electric overhead lights in order to ensure that the home is clean and hygienic throughout. Full information regarding the staff members experience must be made available to the service in order that the staff member is suitably qualified and competent to support individuals in their care. It was noted that the laundry bin did not have a lid and it has been required that this is replaced in order make arrangements to prevent infection, toxic conditions and the spread of infection in the home. Sensory door guards must be fitted to individual’s bedroom doors if they prefer them to remain open in order to ensure the safety and welfare of all people in the home. 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. The summary of this inspection report can be made available in other formats on request. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 9 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.V344604.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5, Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. Prospective individuals or their representatives do not have accurate information about the home or the fees payable. Arrangements for a needs assessment for prospective individuals ensure that their needs are assessed and identified before admission to the home. All individuals in the home must have an up to date copy of their terms and conditions of stay in the home. EVIDENCE: The home has had no admissions since the previous inspection. The home has a corporate admission policy and procedure, which details the process to be followed for prospective admissions to the home to ensure that individual’s needs could be met. The inspector sampled the homes Statement of Purpose and in discussion with the representatives of the service it has been required that the document must be updated to include the home’s current complaints procedure as the one sampled was dated 2002 and contained information regarding contacting the National Care Standards Commission (NCSC) and should refer the reader to the Commission for Social Care Inspection (CSCI); the details of the manager Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 11 need to be updated, the staffing numbers and current training for example staff achievements of the National Vocational Qualification (NVQ). Requirements have also been made that the Statement of Purpose must be made available upon request to any individual living in the home or their representative. A copy must be sent to the Commission for Social Care Inspection (CSCI). It was noted that at the previous inspection a requirement that the home provide CSCI with a copy of the homes Statement of Purpose and Service User Guide had been met. The inspector advised the individuals representing the service that home must keep the Statement of Purpose and Service Users Guide under review and notify the CSCI and individuals living in the home of any revision within 28 days. The inspector sampled the homes Service User Guide and noted that each individual living in the home has a separate copy, which has been developed with photographs and symbols to illustrate what the home has to offer and what facilities are available. The guide also contained three separate documents of how an individual can make a complaint. It has been required that the complaints procedure which is more suitable for the needs of individuals at the home be used in order that they have the information available to them should they wish to make a complaint. It has been recommended that the home provide a statement within the service users guide to advise that a full copy of the complaints procedure would be made available upon request. The inspector sampled two individuals files and noted that the home had obtained documents regarding the terms and conditions of residency in the home. Both documents were dated 2005/2006. In discussion with the service manager it was agreed that the documents required updating to include the current range of fees. The service manager advised that these could be obtained through the finance department of the Avenues Trust. The home has maintained close bonds between people living in the home and staff and it is apparent through observation that the individuals diversity of needs and preferences of lifestyles are promoted to ensure that all people continue to have a sense and awareness of their individuality. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home has maintained care planning and risk assessments. The documents were current and well recorded to ensure individuals needs and choices were evidenced as being met. People make decisions regarding their lives and participate in the running of their home. EVIDENCE: Two individuals care plans and person centred plans were sampled by the inspector. The plans contained some evidence that each person had been involved in some way with the development of their plan. For example each plan contained documentation of how the person liked to be addressed, how they chose to communicate, people that were important in their life, how they like and choose to receive support and personal care and the individuals ethnic and cultural background. It was noted that each care needs plan had been kept under review to reflect the changing needs of the individual and arrangements in place to continue to Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 13 support the person with the assistance from their key worker or other staff member. During the sampling of the care plans and person centred plans the managers agreed that due to the management changes in the home some of the documents had not been fully updated yet there was evidence in speaking with the staff and via monitoring behaviour charts that the day to day needs of the individuals in the home were being met. During the site visit the inspector noticed that individuals were moving around their home and garden freely and the inspector met with all the people at home during the inspection. One individual was helping the staff do the vacuuming whilst others preferred to stay in their own space and not openly engage with those around them. The managers explained that some staff had worked with individuals for several years and due to this it assisted individuals to feel secure and safe by staff offering a consistent and predicable routine of care and response to the needs of individuals in the home. It was observed that the care plans contained well documented agreed working practices, which staff implemented whilst supporting individuals. It was noted that the home offers support to individuals with a range of complex needs and this diversity was well managed by home. The AQAA advises that the Avenues Trust have a challenging behaviour support manager and a health and safety advisor who are available to work with staff teams when required. Comments received by individuals significant others and healthcare professionals by CSCI regarding the homes provision of care included ‘the staff know the clients well and are sensitive to patterns of behaviour that could indicate problem’, ‘we are delighted with the care that our relative has received at Chelsham Lodge and the progress they have made.’ ‘ Now they are doing person centred planning and care planning its much better’. The home has maintained risk assessments which include a variety of activities undertaken by individuals for example smoking a pipe, accessing the community e.g. restaurants/pubs, bathing, eating and drinking, using the homes vehicle, using public toilets, going on holiday, and incidences of behaviour which tests the service. All the risk assessments had been appropriately reviewed to ensure the safety and welfare of the individuals and staff. The home supports individuals from ethnic minorities and also has a multi cultural staff team. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 14 It was evident through sampling records and observation in the home that staff members continued to support people with diverse needs in a caring and individualised way in order to promote their individuality and sense of identity. The home has a flexible yet structured atmosphere, which was observed to promote peoples rights to freedom of choice in their home. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15,16,17. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The home promotes and maintains peoples involvement in their community, appropriate activities and maintaining friendships. Improvements are required regarding opportunities for individual’s personal development. Individuals are encouraged to be involved in the running of the home and improving daily living skills. The available choice of food provided was of a good standard yet menus need to be updated. EVIDENCE: On arrival at the service it was noted that one individual was receiving a foot massage from the aroma therapist. Several people were not at home and the pace and atmosphere in the home was calm and relaxed. Whilst talking to the staff they advised the inspector that the activities which people take part in are varied and include daily living skills such as dusting, hovering, and putting clothes in the washing machine/dryer. The managers Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 16 and inspector spoke at some length regarding the development in the home of documentation to identify people’s goals relating to their strengths and building upon these to continue to empower and promote individual’s independence and self esteem. An overall improvement to the person centred plans has been required that the home must ensure that individuals goals and aspirations are documented in order to give a clear audit and review of the goals they have achieved and what they may wish to achieve. It was noted that the home uses some objects of reference to assist individuals in their daily lives and helping people make choices. The Annual Quality Assurance Assessment (AQAA) states that the home has introduced a person centred active support to plan house activities more around the individuals than the staff. The home recognises that they have very few drivers to facilitate more participation and community activities. Whilst speaking with staff the inspector noted that they had made specific links with peoples relatives in order that family and other friendships were maintained. Some individuals at the home speak with their relatives on the phone and others are supported to stay with relatives. It was observed that staff promoted spiritual and religious cultures for one individual relating to their choice of meals and end of life rituals. The inspector observed that the homes dining area was spacious and airy and contained suitable furniture to support people to eat their meals in a comfortable setting with staff support where necessary. One member of staff was in the kitchen preparing the lunch, which comprised of burgers and cold drinks. Whilst sampling the care plans the inspector observed that one individual did not eat certain food due to their cultural background and staff observed this choice. The menus sampled were dated April 2006. The inspector was advised that the menus had been recently reviewed by a staff member yet were not available at the inspection. There was some evidence that the home have input from a dietician and whilst sampling care plans it was observed that people’s body weights were recorded. The home has a record of alternative meals provided to each individual in the home. It has been required that the home must revise their menus to include sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition. The homes fridges and freezers contained, appropriately stored foodstuffs and some fresh fruit and vegetables were also available. It was noted that there was limited foodstuffs in the home and the inspector was advised that a large shop at the local supermarket was due in the afternoon of the inspection. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that individuals receive personal care and attend health care appointments to ensure their wellbeing and welfare. The homes medication procedures are robust to ensure the safety and wellbeing of individuals. EVIDENCE: The two care plans sampled included clear records to demonstrate that the individuals receive personal care in the way they prefer and health care appointments were attended for example visits to the specialist dentist, optician, GP and chiropodist. The inspector was advised that the home has strong links with the local GP who visits once a week and reviews individual’s medication on a regular basis. Records to monitor the individuals specific health care concerns were also well documented and included weight charts, dietician advice, and continence management. The health care records also evidenced that the home had close working relationships with health care professionals. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 18 Records indicated that care plan reviews had taken place and the home were active in seeking advice and support from healthcare professionals should the need arise to ensure the safety and well being of individuals. The home has a comprehensive, medication policy and procedure regarding administration of medication and uses the monitored dosage system. The medication is stored in a locked cabinet in the home in order to protect people from harm. An audit by the dispensing chemist had been attended in 2006 and all staff had received training in the administration of medicines. The inspector sampled two medication administration charts, which were in good order. The home has clear written protocols regarding the administration of PRN medication and how individuals prefer to take their medication. The staff advised that no individual is given covert medication and it has been recommended as good practice to include a statement in the medication policy and procedure that individuals have a right to refuse their medication if they choose. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is adequate. This judgement has been made a range of evidence including a visit to this service. The home must review their complaints procedures. The home has a Safeguarding Adults (Adult Protection) policy and procedure to ensure that individuals are adequately protected by the same policy and procedure. EVIDENCE: As previously documented at the beginning of the report the home has three separate documents of how an individual can make a complaint. It has been required that the home ensure that the complaints procedures contain appropriate information and are written in a format which is understood by individuals associated with the service in order that they have the information available to them should they wish to make a complaint. The managers explained that no complaints have been received by the home except reminders from a neighbour about cutting the hedge, which surrounds part of the service. The comment cards received by the inspector indicated that people knew how to complain or raise concerns and comments. The home has not been subject to any safeguarding referrals since the previous inspection. The manager explained that staff had received training in safeguarding vulnerable adults and awareness of safeguarding issues were also explained in the staff induction training. Training plans were sampled by the inspection to verify this information. The managers explained the safeguarding protocols to the inspector at the time of the visit. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 30. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The home offers a comfortable and homely environment. People’s bedrooms reflect their individuality. Communal areas, including bathrooms in the home were spacious, well decorated and maintained to meet the current needs of individuals. Further decoration, repairs and hygiene standards need to be implemented. EVIDENCE: The home continues to offer a homely, clean and comfortable environment. It was apparent that the manager and staff have made a significant effort to provide attractive ornaments and household furnishings, which greatly enhance the home to make it feel like home. The homes lounges, quiet area and dining areas were spacious and well decorated. Individual’s bedrooms contained personal possessions, including furniture of their choice, soft furnishings, framed family photos and spiritual icons, which Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 21 reflected their individuality. During the tour of the premises the inspector noted that all individuals rooms were decorated to a high standard and were areas, which offered individuality and peoples own space. It has been required that one individual’s bedroom flooring required re adhesive or replacement due to wear and tear. It was recognised during the inspection that the individuals living in the home were not aware of the wear and tear of the homes furnishings. Staff advised that they keep a maintenance record with regard to the repairs within the premises and this was evidenced by a maintenance plan given to the inspector at the time of the inspection. The maintenance plan will be held with the service inspection documents and it has been requested that the completion of the repairs be forwarded to CSCI. It was acknowledged that the maintenance person was due to visit the home the day after the inspection and several areas identified on the maintenance list had been observed by the inspector during the inspection. Additional items for repair or maintenance included the replacement of an individual broken chest of drawers, which the key worker advised was on order. The inspector noted that the homes bathrooms, walk in shower and toilets were in working order, clean and well decorated. Further plans were in place to furnish the rooms with more homely ornaments. During the tour of the premises the inspector noted that there were areas within the kitchen that required cleaning for example in cupboards, surrounding pipe work and the covers of the electric overhead lights. The staff explained that the kitchen had been recently painted however a requirement has been made that these areas are cleaned in order to ensure that the home is clean and hygienic throughout. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers an induction and training development programme to ensure that staff are competent to support the needs of the individuals. Staff recruitment practices must be improved to ensure staff competency. EVIDENCE: Comments received by the commission regarding the staff stated ‘the carers seem to have genuine regard for clients and have strong relationships with them’ ‘I admire and respect the staff at Chelsham Lodge’. Staff comments included ‘I feel a lot of the time an extra member of staff in the afternoon would benefit the service users as generally only one can leave the house at a time.’ ‘The staff meet the daily needs of very complex service users and have a good understanding of those people using the service’. ‘I would like to be better at interpreting PCA’S to those service users who would benefit from it’. ‘The Avenues Trust trains its staff regularly; supervisions are done on a monthly basis. Service users needs and requirements are met on time, team meetings done on a regular basis and effective communication Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 23 regarding any changes or new developments are always practiced by the Avenues Trust’. It was observed that the staff on duty were confident in supporting and encouraging individuals and there was a sense of ease and it was noted that individuals responded favourably to staff. The home currently employs twenty care staff, which includes part time staff. The home currently has care staff vacancies and there has been a turnover of staff during the last year yet a core staff team remain. The staff explained that the use of agency staff is kept to a minimum with only regular agency staff employed to offer continuity of service to the home. The inspector sampled two care staff recruitment checklists, which indicated that CRB, two references and an application form had been completed. There was a section on the checklist, which referred to the individuals experience with working in social care and on each of the forms this had been left blank. This matter was discussed with the service manager who agreed it should have been completed to advise the home manager what experience the individual has to work with people with complex needs. It has been required that full information regarding the staff members experience must be made available to the service in order that the staff member is suitably qualified and competent. The inspector sampled that the home have structured induction training programme which links with the Learning Disability Awards Framework (LDAF) and the National Vocational Qualification (NVQ). Statutory training for example fire safety, moving and handling, food hygiene, health and safety including risk assessments is undertaken during the staff member’s induction. The AQAA states that four staff have achieved their level 2 or above National Vocational Qualification (NVQ) with two staff working toward gaining the achievement. It is noted that the home would like to see an increase in these numbers. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The overall management of the home is good and individuals and their representative’s views are considered. Health and safety arrangements are generally well managed to ensure the safety and welfare of all people in the home. EVIDENCE: The management of the home has recently changed and the current manager had been in post for four days. The manager explained that the Avenues Trust had moved the previous manager to another Avenues Trust service. Comments received by CSCI regarding the management arrangements of the home included ‘ Our only reservation might be that there have been frequent changes of staff at the top, but we have had no criticism of any individual concerned and changes may be inevitable in the care of challenging Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 25 behaviour’. ‘ Staff vary; lots of managerial changes have led to inconsistencies in how people are managed’. ‘High turnover of staff’ ‘The home would improve by good consistent lead from the top and employing skilled staff. The home has complex cases and changes to the management have not helped’. ‘I feel the service would benefit from better support from Head Office in getting staffing levels right including those at management level’. The current manager has achieved the registered managers award and throughout the inspection demonstrated knowledge of the responsibilities and skills in management of the home. It was recognised during the inspection that the deputy manager had had significant input in the management of the day to day running of the home and made significant contributions to the inspection process. The inspector observed that the office location was central to the home and people and staff have access to the manager and the office space. The home were not aware of the updated Care Homes Regulation 2001 (updated July 2006) and must obtain a copy to ensure compliance with their statutory obligations. It was evident during the inspection that individuals were encouraged and able to voice their opinions about the service and attend home and key worker meetings if they chose to. The home has a quality assurance process, which actively seeks the views of all people connected to the home. The inspector sampled a variety of health and safety records, which included water, fridge and freezer temperatures, accident and incident records, fire drills, practices and noted that the fire extinguishers had been serviced. It was noted that the laundry bin did not have a lid and it has been required that this is replaced in order make arrangements to prevent infection, toxic conditions and the spread of infection in the home. During the tour of the premises the inspector observed that several individuals bedroom doors were propped open and it has been required that sensory door guards must be fitted to individuals bedroom doors if they prefer them to remain open in order to ensure the safety and welfare of all people in the home. It has been recommended that the home consult with the local fire officer regarding this matter. Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 26 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 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 2 X Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 YA1 YA22 Regulation 4. (1 c) 4. (2) Schedule 1 22.(2) 22. (7)(a) 6. (A)(b) Requirement The Statement of Purpose must be updated to include the home’s current complaints procedure, current details of the manager, the current staffing numbers and training for example staff achievements of the National Vocational Qualification (NVQ). The home must keep the Statement of Purpose and Service Users Guide under review and notify the CSCI and individuals living in the home of any revision within 28 days. Both documents must be made available upon request to any individual living in the home or their representative. A copy must be sent to the Commission for Social Care Inspection (CSCI). The home must provide a complaints procedure, which is suitable and appropriate to the needs of individuals living in the home in order that they or their representatives have the information available to them DS0000013595.V344604.R01.S.doc Timescale for action 01/11/07 2 YA1 YA22 22.(2) 22.(7)(a) 01/11/07 Chelsham Lodge Version 5.2 Page 28 3 YA1 4 YA11 5A (2)(a)(i) (iii) (b) 3.(a) Schedule 4 .8 12.(1)(b) should they wish to make a complaint. The individual’s terms and conditions of stay in the home must reflect the current range of fees. The home must ensure that individual’s goals and aspirations are documented in order to give a clear audit and review of the goals they have achieved and what they may wish to achieve. The home must revise their menus to include sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory in relation to nutrition. One individual’s bedroom flooring required re adhesive or replacement due to wear and tear. Areas in the kitchen, which require cleaning, are the cupboards, surrounding pipe work and the covers of the electric overhead lights in order to ensure that the home is clean and hygienic throughout. Full information regarding the staff members experience must be made available to the service in order that the staff member is suitably qualified and competent to support individuals in their care. It was noted that the laundry bin did not have a lid and it has been required that this is replaced in order make arrangements to prevent infection, toxic conditions and the spread of infection in the home. Sensory door guards must be fitted to individual’s bedroom DS0000013595.V344604.R01.S.doc 01/11/07 03/12/07 5 YA17 Schedule 4 .8 01/12/07 6 YA25 16.(2 c) 01/12/07 7 YA30 23.(2)(d) 01/12/07 8 YA32 18.(1)(a) 01/11/07 9 YA42 13.(3) 08/10/07 10 YA42 23.(4)c(i) 01/11/07 Page 29 Chelsham Lodge Version 5.2 doors if they prefer them to remain open in order to ensure the safety and welfare of all people in the home. 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 YA1 YA22 Good Practice Recommendations It has been recommended that the home provide a statement within the service users guide to advise that a full copy of the complaints procedure would be made available upon request. It has been recommended as good practice to include a statement in the medication policy and procedure that individuals have a right to refuse their medication if they choose. It has been recommended that the home consult with the local fire officer regarding sensory door guards to individual’s bedroom doors if they prefer them to remain open. For the home to have an amended copy of the Care Homes Regulations 2001. 2 YA20 3 YA42 4 YA41 Chelsham Lodge DS0000013595.V344604.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000013595.V344604.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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