Inspection on 05/12/06 for Chelsham Lodge

This inspection was carried out on 5th December 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 11 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 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 Chelsham Lodge High Lane Warlingham Surrey CR6 9DQ Lead Inspector Joseph Croft Unannounced Inspection 5 December 2006 10:30 th Chelsham Lodge DS0000013595.V318635.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.V318635.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.V318635.R01.S.doc Version 5.2 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.V318635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of service users is: 37 - 60 YEARS Date of last inspection 22nd May 2006 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.V318635.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a second Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. This inspection was conducted by Mr J Croft on the 5th December 2006, and took six hours, commencing at 10:30 hours and concluding at 16:30 hours. The inspection process included a tour of the premises, sampling of residents’ person centred plans, risk assessments, and staff training documentation that was available. Other documents sampled included policies and procedures, staff duty rota, menu and records of medicines. Discussions took place with the senior care worker on duty and care staff. Staff were knowledgeable about residents’ person centred plans, their likes and dislikes, and how to support them. The inspector saw all seven residents. Due to the degree of learning disability and communication needs of residents living in this home it was not possible to obtain their views about the home or their care. Observations of staff interaction with residents were observed during the inspection. Other evidence has been included from the pre-inspection questionnaire that was forwarded to the Commission For Social Care Inspection Surrey Local Office. Relative/visitors comment cards were sent prior to this inspection, however, only two were returned. Comments in these comment cards were positive about the home, staff and the care afforded to residents. At the time of this inspection the acting manager was on annual leave. The senior support worker on duty assisted the inspector. The home had a random inspection on the 23rd August 2006 at which it was noted that the management of the home had met thirty eight of the requirements made at the previous key inspection, leaving a further five requirements to be complied with. Eleven requirements have been made during this inspection. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The outstanding requirements from the random inspection of the 23rd August 2006 must now be complied with. Records of alternative meals to the menu that have been taken by each resident must be maintained. Staff who administers medication must receive appropriate training in regard to the safe administration of medication. The Service Users Guide must include the correct contact details for the Commission For Social Care Inspection Surrey Local Office. All staff must receive training in the Protection of Vulnerable Adults. Arrangements for the inspection of all records in the absence of the acting manager must be put in place. An action plan with dates must be submitted to the Commission For Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 7 Social Care Inspection Surrey Local Office of how the outstanding issues in regard to the décor and floor coverings of the home are to be achieved. A copy of the plans that are in place to ensure compliance that 50 of support workers (including agency staff) are to attain NVQ level 2 qualifications or equivalent must be forwarded to the Commission For Social Care Inspection Surrey Local Office. An application to register the manager must be submitted to the Commission For Social Care Inspection Registration Team. The Registered Person must ensure the home has an up to date electrical certificate for hard wiring. 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.V318635.R01.S.doc Version 5.2 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.V318635.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Service Users Guide requires updating to enable prospective residents to make an informed choice about where to live. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The Statement of Purpose had been updated, however, the requirement made at previous inspections that a copy of this document must be forwarded to the Commission For Social Care Inspection Surrey Local Office had not been complied with. The senior support worker stated the Service Users Guide had not been fully updated, and therefore a copy of this document has also not been forwarded to the Commission For Social Care Inspection Surrey Local Office. Further requirements in regard to these have been made. The senior support worker informed the inspector that there have been no new admissions to the home since the last inspection. The home follows The Avenues Trust admission policy and procedure. This document gives information on the process to be followed for new admissions, and that only residents whose needs can be met will be admitted to the home. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 10 The senior support worker stated the home is no longer able to meet the assessed needs of one resident, and this person is due to leave the home within the next two weeks. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed Person Centred Plans and risk assessments that ensure the needs of the residents are met. EVIDENCE: Staff at the home are continuing to make progress in developing the Person Centred Plans (PCP). The senior support worker informed the inspector the work on the PCPs is ongoing. This was confirmed during a telephone conversation with the acting manager on the 15th December 2006. Two PCPs were sampled during this inspection and included information in regard to the cultural and religious needs of residents. The PCPs sampled had a Cultural Needs Assessment record that was due to be completed by the key workers. Other information included planned activities, moods and feelings, participation, behaviour, nighttime records and health care needs. Each file sampled contained a profile of the resident, and gave the reader information of how the resident prefers to be supported with their personal care needs. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 12 Evidence of statutory reviews was observed, however, evidence of internal reviewing of care plans could not be viewed. The senior support worker informed the inspector that the acting manager has the review of care plans locked away, and she could not access them. However, during a telephone conversation the acting manager stated that the internal reviews are recorded in a separate folder that is always available in the care office. It is noted that staff and the acting manager have been working hard to develop the Person Centred Plans involving the residents’ and their families. Staff stated they offer choices to residents through the use of visual aids and talking to residents, which was evidenced during this inspection. Records of choices made are maintained. Risk assessments were viewed for two residents and were found to be comprehensive; it was observed that the risk assessments for one resident were only accessible on the home’s computer. All staff have access to the home’s computer, however, a good practice recommendation has been made that copies of risk assessments should be maintained in the PCPs. The senior support worker informed the inspector that risk assessments are reviewed every six months, or as and when required. Risk assessments sampled evidenced they were last reviewed on the 5th November 2006. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 13 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with opportunities to improve their lifestyle and are offered a healthy balanced diet. EVIDENCE: The profound learning disabilities and challenging behaviours of residents living at the home inhibit opportunities to partake in paid employment. Staff were observed interacting with the residents in a caring and supportive manner, talking to residents and allowing them time to respond. Staff were encouraging residents to make choices and join in with activities. Two residents were observed joining in games with staff, others were helping a member of staff with the laundry. Residents were observed to enjoy the interaction with staff. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 14 The senior support worker stated residents have opportunities to attend day centres and clubs during the week if they wish to. The home has a weekly activity sheet that informs staff the days of attendance to the day centres for each resident. During discussions staff stated they take residents to the local community to go shopping, visit the local pub and to have meals at restaurants. These activities are recorded on the individual weekly activity sheets, which are maintained in residents’ PCP files. The home has its own transport, which enables staff to take residents on trips further a field such as to London and the seaside. Staff stated that family and relatives are encouraged to visit the home as and when they are able to. Residents receive letters and telephone calls, and are supported by staff when required. Residents have opportunities to meet with other people outside of the home through attending day centres and functions with residents from other The Avenue Trust care homes. Staff were observed to knock on residents’ bedroom doors, address residents by their first names and interacted with them throughout the inspection. Staff stated residents help with the daily house chores such as cleaning and the laundry. Residents are provided with opportunities, under staff supervision, to take part in some cooking and baking activities. The home uses a four-week rolling menu that was viewed during the inspection. The menu offers balanced meals that include meat, fish, pasta, fresh vegetables and fresh fruit. The senior support worker stated residents are offered another choice if they do not like a particular meal, however, this is not recorded. A requirement in regard to this has been made. Staff were aware of a particular resident’s religious and cultural needs, which is recorded in their care plan. The days menu is displayed in picture format on the dining room wall that informs residents what the days meal is. Food was observed to be appropriately stored in the kitchen and fridges, and records of daily fridge/freezer temperatures being maintained. Records of cooking temperatures were viewed, but records for November 2006 could not be located. Staff undertake cooking duties, training records sampled evidenced training in food handling and hygiene had been undertaken. Evidence was also viewed of letters from The Avenues Trust to staff offering dates for refresher training courses. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 15 Staff stated that in their opinion the food is very good, and residents enjoy the meals. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported in a dignified and respectful manner. Residents are protected by a medication policy; however, training and accurate records of medication require improving. EVIDENCE: Person Centred Plans sampled provided written information in regard to the support required when attending to personal support needs. It was observed during the inspection that personal support is provided in the privacy of residents’ bedrooms. During discussions staff stated they offer residents opportunities to choose their own clothes and hairstyles. The home uses the key worker system whereby care staff work closely with one or two residents, enabling their assessed needs to be met. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 17 Person Centred Plans sampled had a health action plan that included information in regard to health care needs, accidents, NHS appointments and weights. Staff stated any identified health care problems are referred to the appropriate specialist promptly. Records of visits to the GP, Dentist and other health care professionals were observed. The senior support worker stated no current resident self medicates or is taking a prescribed a controlled drug. On the day of the inspection all prescribed lotions and creams were appropriately stored in a secure medical cabinet. The home follows The Avenues Trust Medical Policy and Procedure. The Medical Administration Records were sampled, however, it was noted that for one identified resident, a dose of prescribed medication had not been signed for. A requirement in regard to this has been made. The home maintains records of medicines received and returned to the pharmacist. Evidence of specimen signatures for staff administering medication were observed. However, evidence that all staff had received training in the safe administration of medicines could not be ascertained. Evidence was viewed that dates for attending refresher training for some staff had been booked for 31st January 2007. A requirement has been made that the registered person must ensure all staff administering medication undertake the appropriate training in regard to the safe administration of medication. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues, however, all staff must receive the appropriate training in regard to the protection of vulnerable adults. EVIDENCE: The organisation had a complaints procedure that had been produced in various formats including a pictorial format, audiocassette and a CD. A copy of the complaints procedure was observed in the Service Users Guide that was in the process of being updated. However, it was observed that this complaints procedure did not have the correct contact details for the Commission For Social Care Inspection Surrey Local Office. Staff stated they are able to tell if residents are unhappy by their body language, facial expressions and that residents will find a way of communicating their moods to staff. Staff stated they would forward complaints on behalf of residents to the home’s acting manager or area managers, and if necessary, would contact the Commission For Social Care Inspection Surrey Local Office. The complaints records could not be evidenced during this inspection due to it being kept in a locked cupboard that is only accessible by the acting manager. Staff at the home follows The Avenues Trust Protection of Vulnerable Adults Policies and Procedures. The home had a copy of the Surrey Multi-Agency Procedures February 2005. During discussions staff were able to give an Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 19 accurate account of the action to be followed in the event of abuse. Staff stated they would not hesitate to report bad practice, and would contact the Commission For Social Care Inspection if they were not satisfied with outcomes in regard to this. Staff training records available on the day of the inspection evidenced that not all staff had received training in the Protection of Vulnerable Adults. A requirement has been made that the registered person must ensure all staff attends training on the Protection of Vulnerable adults. It was not possible to check residents’ monies, as these were inaccessible on the day of the inspection. Chelsham Lodge DS0000013595.V318635.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, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate communal and individual living space making it a comfortable place to live, however, identified areas require attention. EVIDENCE: A tour of the premises was undertaken during this inspection and the home was found to be clean and tidy. The lounge had been redecorated throughout and furnished with new settees and lounge chairs. This room also had ornaments and plants that made it an attractive and homely environment. Staff stated they were hoping to further enhance the lounge with the possibility of opening up the fireplace. It was evident that redecoration of the home had commenced, and other repairs were in progress. Some bedrooms had been redecorated; others were waiting to be completed. The bathrooms had been supplied with soap dispensers and paper towels; however, the senior support worker informed the inspector they were experiencing difficulties with one resident in regard to these. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 21 It is acknowledged that the redecorating of the home had commenced, however, there are still some outstanding issues in regard to the décor. The ground floor bathroom requires attention to the ceiling and replacement of door handles, one identified resident’s bedroom has sustained damage to the wall, and the window frame had buckled. Two identified bedrooms require attention to the decoration, and the first floor bathroom had a leaking toilet that was repaired on the day of the inspection, but the floor covering needs to be replaced. The senior support worker informed the inspector that the new carpets and floor coverings had been ordered, but was unsure of a delivery date. A requirement has been made that the registered person must forward an action plan with timescales of how the identified issues in regard to the décor and floor coverings of the home are to be addressed. Chelsham Lodge DS0000013595.V318635.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 and 35 could not be accessed due to access to these records. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Documentation available on the day evidenced staff receive regular opportunities to attend training. No evidence was available to assess Standards 34 or 35. EVIDENCE: On the day of the inspection staff were observed to be approachable, patient and had the ability to engage with and understand residents’ needs and wishes. The staff duty rota evidenced that there are five staff on duty during the early shift and one activity co-ordinator; five staff on duty for the late shift and three waking night staff cover the night duties. Staff at the home follow The Avenues Trust training and development policy. Evidence was viewed of letters sent to staff by the organisation offering places on various internal training courses. Although some records in regard to training were viewed, it was not possible to evidence training in regard to NVQ. The senior support worker stated that the Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 23 acting manager maintains staff training files in a locked cupboard that could not be accessed by other staff. It was a requirement from the random inspection of the 23rd August 2006 that the registered person must ensure plans are in place for compliance with the standard for 50 of support workers (including agency staff) to attain NVQ level 2 qualifications or equivalent. As it was not possible to evidence this, a requirement has been made that the registered person must forward a copy of the plans that are in place to ensure compliance that 50 of support workers (including agency staff) to attain NVQ level 2 qualifications or equivalent. The staff recruitment files were not accessible on the day of the inspection. The senior support worker informed that the acting manager had these stored in a locked cupboard to which no other staff can access. A requirement has been made in regard to this. Chelsham Lodge DS0000013595.V318635.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The foundations are in place for the home to be well managed but certain issues need to be addressed. EVIDENCE: The home had an acting manager in post who was on annual leave at the time of this inspection. Evidence from the last key inspection informs that the acting manager had commenced working at the home in February 2006, and possesses the relevant qualifications, knowledge and experience to manage the home. Staff members spoken to during this inspection were complimentary about the acting manager, her commitment to the home, the improvements she has Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 25 made to date and her open and honest style of management. Staff informed the inspector that they feel much more involved in the running of the home. The Commission For Social Care Inspection Registration Team informed the inspector that an application to register had not been received from the acting manager at the time of this inspection. A requirement in regard to this has been made. The Avenues Trust continues to conduct monthly visits to the home in the form of Regulation 26 visits; copies of these are being forwarded to the Commission For Social Care Inspection Surrey Local Office. An annual survey of the views of relatives and other associated professionals has been conducted by the organisation. Documentation viewed provided evidence that The Avenues Trust is committed to providing training to staff working at the home, to ensure they are trained to undertake the work they do. As stated under Standard 32, it was not possible to fully evidence all staff training records on the day of this inspection. A requirement has been made under Standard 23 in regard to Protection of Vulnerable Adults training. The home has a designated senior member of staff to monitors health and safety issues on a monthly basis. The following health and safety records were sampled during this inspection: Gas safety certificate, portable electrical appliances, fire risk assessments, maintenance records of fire fighting equipment and records of fire drills. The requirement made at the two previous inspections have not been complied with, that the home must have a current electrical certificate, and a copy must be forwarded to the Commission For Social Care Inspection Surrey Local Office. This requirement is to be carried forward and must now be complied with. Chelsham Lodge DS0000013595.V318635.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 X 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 2 25 2 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 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 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(2) 6 (b) Requirement For the Registered Person to ensure that the updated Statement of Purpose and Service Users Guide is copied to the CSCI. The Service Users Guide must also include information in accordance with Regulations that came into force on 1st July 2006. This requirement is carried over from the previous two inspections, and must now be complied with. The Registered Person must ensure records are maintained of alternative meals to the menu that have been taken by each resident. The Registered Person must ensure that all medication administration records are signed. The Registered Person must ensure all staff receive appropriate training in regard to the safe administration of medication. The Registered Person must DS0000013595.V318635.R01.S.doc Timescale for action 14/01/07 2. YA17 17 (2) Sch 4 (13) 17 (1) (a) Sch 3. (3) (i) 18 (1) (c) (i) 12/12/06 3. YA20 06/12/06 4. YA20 31/01/07 5. YA22 22 (7) (a) 14/01/07 Version 5.2 Page 28 Chelsham Lodge 6. YA23 13 (6) ensure the complaints procedure in the Service Users Guide includes the correct contact details for the Commission For Social Care Inspection Surrey Local Office. The Registered Person must ensure all staff attend training on the Protection of Vulnerable Adults. The Registered Person must forward to the Commission For Social Care Inspection Surrey Local Office, an action plan with timescales of how the identified issues in regard to the décor and floor coverings of the home are to be achieved. The Registered Person must forward a copy of the plans that are in place to ensure compliance that 50 of support workers (including agency staff) are to attain NVQ level 2 qualifications or equivalent. 31/01/07 7. YA24 23 (2) (b) (d) 31/12/06 8. YA32 18 (1) (a) 31/12/06 9. YA34 17 (3) (b) Schedule 4 (6) 10. YA37 11. YA42 The Registered Person must ensure arrangements for the inspection of staff recruitment files and other records are in place for inspection purposes. 4 (3) (b) The Registered Person must Section 24 ensure an application to register CSA 2000 the manager is submitted to the Commission For Social Care Inspection Registration Team. 23(2)(b), For the Registered Person to (4) ensure the home has a current electrical certificate for hard wiring. A copy of this evidence to be forwarded to the CSCI. This requirement is carried over from the previous two inspections, and must now be complied with. 31/12/06 31/12/06 31/12/06 Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 29 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 YA9 Good Practice Recommendations Copies of risk assessments should be maintained in the resident’s Person Centred Plans. Chelsham Lodge DS0000013595.V318635.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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