CARE HOME ADULTS 18-65
Chelsham Lodge Chelsham Lodge High Lane Warlingham Surrey CR6 9DQ Lead Inspector
Pat Collins Unannounced Inspection 14:00 8 & 17 November 2005
th th Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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.V264134.R01.S.doc Version 5.0 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.V264134.R01.S.doc Version 5.0 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.V264134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of service users is: 37 - 60 YEARS Date of last inspection 26th July 2005 Brief Description of the Service: Chelsham Lodge is a care home registered for personal care provision for seven adults with learning disabilities, including individuals with autistic spectrum disorders and behaviours that challenge conventional services. Currently the user group is all male. The home is managed by The Avenues Trust and is part of a group of homes operated by this organisation in Surrey and Kent. Chelsham Lodge is conveniently located near to shops and other community facilities in Warlingham village. A large supermarket and a public house are within walking distance. Leisure and larger shopping facilities are accessible by car or public transport in nearby towns. Situated in a semi-rural location, the home is set back from the main road and access arrangements ensure safety and security of service users. The very large garden is bordered by open land and affords a secluded, private area. Adequate car parking facilities are available and service provision includes a seven seat ‘people carrier’ vehicle. Chelsham lodge is a detached, large, two story building. The all – single bedroom accommodation is on both floors. Access to the first floor is by stairs only. Toilet and bathing facilities are within close proximity of bedrooms. Communal facilities are on the ground floor, comprising of a spacious lounge, an activities room and separate dining room. There is a domestic style, fitted kitchen and separate utility room. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the home’s second inspection for the year 2005/2006. The inspection was unannounced, that is, staff and service users received no prior notice that it was to take place. The inspection was carried out over two half days. On the first day the visit commenced at 14.00 hrs and concluded at 18.45 hours. On day two the visit began at 13.00 hrs and finished at 16.00hrs. The home manager was present on both days and the service manager present on day two. The inspection process involved following up progress for meeting requirements made at the time of previous inspections. Discussions with management focused on day and night staffing levels and their adequacy to meet needs; additionally on assessment and management of risks, areas of care practice and on the physical environment of the home. The ongoing failure to make application for registration of the home manager was raised as a matter for urgent attention. A sample of records was examined and food preparation and a meal partly observed also elements of care practice. A tour of the premises was carried out and opportunity taken for consultation with staff. The inspector was introduced to all service users. Communication with service users relied heavily on the skilled assistance of staff using a combination of gestures and some signing to illicit information; also by direct observation of body language and behaviours effort was made to assess service users wellbeing. Only one service user had limited verbal language skills. The inspector would like to thank the service users and the staff team for their hospitality and cooperation throughout this inspection. What the service does well:
The home had a stable staff team ensuring good continuity of care. The manager reported that the home was now operating on an almost full staff compliment and that there had been no staff turnover since the time of the last inspection. Staff on duty were perceived to have sound knowledge of the service users needs. Discussions with the manager and observation made of records indicated that arrangements were made to offer most service users a varied programme of activities despite their profound disabilities. Arrangements included provision of two escorted holidays for most service users per annum. This was intended to supplement current provision for social and leisure opportunities provided by the team and Surrey Oaklands NHS Trust day services staff. The manager stated that one service user had been unable to go on holiday this year for reason’s related to his medical problems. The small group holidays afforded a higher staff ratio than routinely provided for some service users, which was to their benefit. He described how these
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 6 holidays enhanced service users’ learning and development opportunities and experiences. Records demonstrated commitment to ensuring staff received mandatory induction and foundation training and provision of service specific training. It was positive to observe that the home manager and two senior support workers had attained the registered managers award qualification. The home manager informed the inspector he was a qualified nurse (learning disability) and possessed an NVQ Level 4 management certificate. The manager advised also of staff’s efforts for maintaining relationships between service users and their relatives. The organisation’s quality assurance system ensured annual satisfaction surveys sent to service users advocates, relatives and representatives. The last survey was carried out in August 2005 and the two questionnaires returned demonstrated a high level of satisfaction with service provision and standards of care. Comments from a relative in a returned questionnaire included “staff do a wonderful job”, “ I am very happy with the care” and “ I am grateful to know my relative is well looked after at Chelsham Lodge”. The manager confirmed an action plan in place for addressing some environmental deficiencies. It was reported that some deficiencies had already been remedied and for others, that work was imminent. There was stated to be plans and agreed funding to replace missing curtains and blinds in the lounge and to replace new settees and a dresser. It was also confirmed that funding had been agreed for provision of a suitable shower facility for meeting the needs of a service user unable to safely use existing bathing facilities. Observations confirmed provision of a nutritious menu and of good quality, substantial, home cooked meals. What has improved since the last inspection?
The manager reported further redecoration had taken place since the last inspection. The home was clean and tidy and odour control was overall satisfactory. An action plan for further improvement to odour control was noted. The requirement to replace rotting wood around sinks in bathrooms had been met. Staff had allocated times for encouraging service users to engage in domestic routines, for example tidying bedrooms and wardrobes, sorting laundry and changing bed linen. This was undertaken under close supervision and took account of individual capabilities and behaviours. Some service users were unable to take part in various domestic and social activities on the basis of high risk. Staff were observed to spend time with service users during the inspection promoting socially acceptable behaviour. Interaction was ageappropriate and demonstrated good understanding of individual needs.
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 7 What they could do better:
At the time of the last two inspections concerns had been drawn to the attention of management that staffing levels at night appeared inadequate. Whilst acknowledging that staffing levels were stated to have been reviewed observations during this inspection demonstrated that the review had not taken into account all significant factors and risks. The manager was unable to substantiate to the satisfaction of the inspector that night staffing levels were adequate and immediate requirement was made for increase in waking night staff pending further review. Subsequent to the inspection the Commission agreed with senior management that from 9th November 2005 that an additional waking support worker would be deployed on night duty. These revised staffing levels will be maintained pending the outcome of a fundamental review of night staffing levels at the home and agreement with the Commission on minimum staffing levels to ensure provision of safe and appropriate care. Feedback from the manager and staff identified frustration that the day staffing levels were also in their view not adequate for the assessed needs of individual service users to be met. Staff gave examples of times when individual service users warranted staffing ratios of 1:1 to enable them to meet needs and provide safe and appropriate care practices. This had been discussed at the time of reviews and fed back to senior management however action not evidently taken. An additional factor was the long-term deployment of a support worker on food preparation duties that depleted further daytime staffing levels though a budget for a cook existed. In this particular home service users do not engage in preparation of food on the grounds of safety and hygiene. On this basis the case for a full time cook is clearly evident to enable support workers to engage with service users. The manager confirmed a recent positive development of the appointment of a new cook though this individual was not in a position to take up post owing to incomplete vetting procedures. Observations identified that the corporate fire risk assessment was incomplete. The local fire risk assessment was not considered to contain sufficient detail and therefore required further development. This risk assessment did however identify two service users that would be potentially at risk in the event of a fire. These risks were not recorded but explained by the manager to the inspector. It was concerning that the fire procedures did not contain clear instructions for managing these risks. Discussion with the manager identified no formal training available for managers related to carrying out fire safety risk assessments. Observations confirmed the need to develop a coherent policy setting out clear expectations of staff specific to administration of rectal medication for treatment of multiple seizures. Though staff had received training in this intervention from the district nurse, records did not evidence assessment of
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 8 practice competence. The manager informed the inspector that his expectation was for staff to summon the emergency services and not to administer rectal Stesolid medication. Discussed was the need for a clear policy decision on whether staff should or should not administer this medication and development of a protocol for staff guidance in when to call on emergency services. Whilst it is acknowledged that areas of the home had been redecorated and the manager reported that this had improved the environment, attention was needed to paint splashed on ceilings and door and window frames and water damage to a ceiling. This would further enhance the appearance of the environment. The manager informed the inspector of ongoing problems with drainage that was the cause of damage to floor coverings. He also reported difficulties in securing the cooperation of the landlord agency for attention to this issue and other remedial and maintenance matters. Further attention was required to personnel records held in the home. An application for registration of the manager is required to be submitted as a matter of urgency. An application for variation of the home’s conditions of registration was also required. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Prospective service users and/ or their representatives have access to comprehensive information about the services and facilities of the home to enable informed choice about placements. EVIDENCE: The home has recently reviewed and revised its statement of purpose and service user guide. The changes ensured accurate depiction of service provision and amended the title of the regulatory body. The content of the service users’ guide was more accessible to service users through use of pictorial and symbol images. The manager agreed to forward an amended statement of purpose to the Commission for the service file. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Further attention was required to risk assessments for individual service users and their relevance to the safety and suitability of care and adequacy of staffing levels. EVIDENCE: Observations indicated that staff diligently identified risks in the home and external environment. Preventative and appropriate action was being taken within the limitations of staffing levels constraints for the protection of service users; this was achieved through risk assessments and risk management strategies. Service users had limited awareness of personal safety and environmental dangers. Discussions with the manager and staff identified risks related to night care practices not evidently fully addressed. Examples of risks were potential difficulties for carrying out fire evacuation procedures, specific to two named service users. The management of these risks had not been adequately thought through and incorporated into the local fire safety procedures and communicated to the team. The manager was unable to demonstrate adequate night supervision of service users on the current staff ratio of one support
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 12 worker to six service users. It was evident that there was a significant amount of activity including care interventions during the night to engage the attention of this one worker, potentially leaving other service users without supervision. Risks relating to one staff member at night managing behavioural and other potential incidents did not appear to have been adequately considered when setting night staffing levels. Risk factors relating to domestic tasks carried out at night by staff had not been adequately assessed. Observations confirmed a significant change in the behaviour of a service user whose unpredictable and recently aggressive behaviour had resulted in temporary exclusion from day care services on day one of the inspection. This was aimed to safeguard other service users participating in day care activities. No additional staff resources were available for an increase of staffing levels to reflect the increase in observation necessary to contain the heightened risk posed to service users, staff and visitors by this individual. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 and 17 Arrangements for service users to take part in appropriate activities and be part of the community existed, with some constraints. Contact with relatives and advocates was promoted. Provision was made of a healthy, well balanced diet. EVIDENCE: The profound learning disabilities and challenging behaviours exhibited by service users inhibit opportunities for employment or further education. Six service users were funded for a total of 30 hours weekly day care provided by Surrey Oaklands NHS Trust. Additionally the home’s staff spent time with service users in the activities room containing sensory equipment and other suitable activity materials. Staff informed the inspector that they accompanied service users on walks in the grounds and locally and took service users out for drives in the home’s vehicle when approved drivers were on duty. It was noted that two service users required a ratio of 2:1 staffing when out in the community based on risk assessment outcomes. Two service users also required use of wheelchairs when out in the community. The manager informed the inspector of one service user whose care package did not include day care services. Currently this individual was expected to part
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 14 funded provision of a half day session at a day care facility, the remaining costs met from the home’s activity budget which was for all service users to share. At the time of a recent review by this individual’s care manager this deficiency in the care package was recognised. The care manager was understood to be making application for additional funding for day care activities. The manager confirmed arrangements for all service users to have two holidays per annum. It was stated that The Avenues Trust funded one holiday and service users contributed to the cost of the second holiday. Recent holidays were reported to have been successful and to have had positive outcomes for service users. The holiday group size was stated to be three staff to two service users. The inspector observed from the literature available on the holiday accommodation used that this was of a high standard. The manager confirmed comprehensive risk assessments carried out in relation to holiday activities and of accommodation. Observations confirmed varying degrees of involvement and contact between the staff and with service users relatives and advocates, determined by individual circumstances. Food storage, menu planning and food preparation was inspected and found to of a good standard. The manager stated that the whole team had received basic food hygiene training. Senior support workers and support workers shared responsibilities for preparation of all meals. Feedback from staff confirmed only one service user who could engage in the activity for purchasing food for the home from the supermarket. The key worker of another service users was stated to be working towards gradually introducing this individual to this activity of daily living. Discussions with staff established that service users were not involved in preparation of meals or in making drinks. One service user did sometimes engaged in making a cup of tea under supervised instruction. A rotating, seasonally adjusted menu was observed. This menu was varied and in the event of changes to the menu a record was maintained of alternative meals. Service users evidently enjoyed the meal of roast chicken joints, fresh vegetables, potatoes and gravy on day one of the inspection. The inspector part observed meal – time practices. Three service users received staff support at the mealtime observed to modify feeding skills and safe guard service users from the risk of choking. Adapted cutlery and plate guards was provided to promote self – feeding skills. The meal observed on day one of the inspection was substantial in quantity and when sampled found to be appetising and well cooked. On day two the inspector was invited to join service users and staff at the dining table for a cup of tea in the afternoon. Staff were observed to engage in age appropriate conversation with service users and to encourage socially appropriate behaviours. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 15 The large dining table in the dining room was suitably presented for the meal on day one of the inspection, set with a tablecloth, cutlery and pottery mugs for the drink accompanying the meal. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication practices were inspected at the time of the last inspection and considered satisfactory. Observation of medication practices was limited to one specific element and requirement made for improvement in policies and records specific to this area of practice. EVIDENCE: Observations of medication practices were confined to following up recent staff training for administration of rectal Stesolid for the treatment of multiple seizures. It was noted that support workers who had received this training had not been assessed as competent to do so. In discussion with the manager it was stated that it would be his expectation for staff to call the emergency services in such circumstances. The need for a clear policy to be drawn up setting out this expectation of staff was discussed with the manager. A protocol must also be developed to inform staff’s judgement on when to call the emergency services in response to a service user having seizures. Discussed were current arrangements for nail care. At the time of the inspection service users all received regular input from a chiropodist. A recent memo from senior management had clarified expectations for support workers to cut toenails as part of their duties for provision of personal care. Advice was given for the organisation to have in place training for support workers for nail
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 17 care. For individuals where there is a medical diagnosis or other risk factors it was strongly recommended that only a qualified specialist provide this service. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 These standards were assessed as met at the time of the last inspection. The limited scope of this inspection identified the need to reissue the complaint procedure to relatives and for staff who had not yet had adult protection training to receive the same. EVIDENCE: Observation of recently returned questionnaires by relatives/representatives of service users as part of the home’s quality assurance systems, identified that both respondents were unclear of the home’s complaint procedure. Discussed was the need for follow up and for the complaint procedure to be reissued to significant stakeholders. The home’s records confirmed a rolling programme of adult protection training for staff. Observations identified six staff had not yet received this training. No formal complaint had been made to the home since the last inspection. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 and 30 Whilst overall the home environment was ‘fit’ for purpose and provided an acceptable standard of accommodation, attention was needed to maintenance arrangements and to décor and some refurbishment. Improvement was also required to the home’s fire risk assessment and fire procedures. EVIDENCE: The location of the home was considered suitable for its stated purpose. It is within easy access to shops and all community amenities. The premises were suitably secure and spacious, the design of the environment adequate to meet the individual and collective needs of service users. Areas of discussion with the manager included the need for a comprehensive fire risk assessment to be in place. The manager confirmed that recommendations of Surrey Fire & Rescue service in 2002 had been met. It was positive to note a programme for redecoration and replenishment of furnishings. Discussed was the need for attention to paint splashes on ceilings, door and window frames to improve the general appearance of the environment. The manager confirmed funding had been identified for provision of a suitable shower to meet the assessed needs of a service user who had difficulty in safely accessing current bathing facilities. New settees had been
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 20 purchased and other settees in the lounge were to be replaced and a new furniture unit purchased. The manager confirmed plans for the replacement of missing curtains in the lounge. These had been pulled down and fittings damaged by service users. Throughout areas of the home, blinds and curtains had been damaged and were missing. The manager stated this was an ongoing problem. Consideration was recommended for finding a long-term solution by instituting a programme of fitting external blinds that are operational from the interior of rooms, which would be more suited to the home’s stated purpose. The need to assess the needs of individuals who were observed to only have net curtains fitted to their bedroom windows was discussed with the manager. Whilst noting the manager’s assurances that these rooms were not overlooked there is a need to be satisfied that early morning daylight does not unduly disturb sleep. Observations confirmed flooring that required replacement in areas of the home. On the basis that the manager assured the inspector that a programme for replacement was in progress this was not made a requirement. Damage to floor coverings was stated to be caused by faulty drainage under floors. The manager advised of difficulties experienced in securing the landlord’s cooperation in meeting maintenance obligations. The inspector was informed of failure by the landlord to respond to multiple correspondence for essential repairs to the roof which had posed a health and safety risk. He advised that ultimately he authorised these repairs and the charge for the work forwarded to the landlord. The standard of cleanliness and hygiene in the home was overall satisfactory at the time of the inspection. The manager had recently had a washbasin removed from a bedroom in response to the behaviour of a service user to eradicate malodour in this room. Floor covering in this room and in a corridor was due to be replaced for the same reason. Malodour was very strong in the corridor near the office on day two of the inspection. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 34 Staff on duty appeared committed to supporting service users. Staff induction and foundation training needs were mostly met. Night staffing levels were considered inadequate and immediate requirement was made for increase in waking night staff pending further review and risk assessment and agreement on safe staffing levels between the organisation and regulator. Feedback from staff highlighted the potential for an increase in day staffing levels to ensure needs can be safely and appropriately met. Service users were supported and protected by the home’s recruitment policy and practices. Attention was drawn to missing statutory documentation from personnel files. EVIDENCE: Training and development records for staff demonstrated staff received induction and most foundation training, though six staff had outstanding protection training. A programme of NVQ training was stated to be in place though not well established. Only one staff member had attained NVQ Level 2 certificated training and was now studying for NVQ Level 3. The manager stated that some staff had recently commenced the NVQ programme and some staff did not require NVQ training owing to possessing professional nurse qualifications. The home’s usual staffing levels afforded six staff excluding the manager on the early shift and five staff on the late shift. On day two of the inspection this had been adjusted to four staff on both shifts to reflect two service users, one
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 22 of whom received 1:1 24-hours staffing ratio, on holiday. The role of support staff was generic at the time of the inspection. They were responsible for cleaning, catering and gardening tasks. The manager confirmed the recent recruitment of a qualified cook who was currently going through the organisation’s recruitment vetting procedures. The manager and staff were clear that staffing levels were overstretched at times during the day to meet the individual needs of service users. Staff identified individuals who required 1:1 staffing levels that were not provided within the establishment’s staffing levels. In addition to one service user was funded for 24-hour 1:1 care and a second service user funded for 10 hours daily 1:1 care, two other service users were identified by staff to require a substantial number of 1:1 care. Staff described risks and significant difficulties at times in meeting the needs of these individuals’ within current staffing constraints. Monday to Friday day care services provided by Surrey Oaklands NHS staff supplemented this staffing ratio. Discussions in this matter with the service manager and manager confirmed the intention to carry out a fundamental review of the home’s staffing levels. A full needs assessment was to be carried out for each service user and review of staff working practices an routines to underpin a review of staffing levels. Night staffing levels were two waking night staff. The manager stated that the staff member designated responsibility for 1:1 care of a named service user was expected to be in this individual’s room throughout the night. It was not established whether this was the practice. The remaining staff member was expected to assume responsibility for the care and observation of six service users accommodated on two floors. There was noted to be significant nighttime activity and failure to identify and adequately consider various risks when setting night staffing levels. Examples were for the management of aggressive or self-injurious incidents or other challenging behaviours or medical emergencies that warranted two staff. Risks related to the fire procedures at night had not been fully assessed or considered in the context of how two staff could manage these at night. A personal risk assessment for a member of the night team had not yet been carried out. The current night staffing levels did not allow for staff breaks as far as could be ascertained based on the information supplied by the manager. Responsibilities for domestic work carried out by night support workers needed further consideration as part of the staffing review. The manager reported a successful recruitment initiative since assuming responsibility for the management of the home. It was stated that the team was now stable, affording continuity of care. Staff turnover was reported to be minimal and for reasons of career progression by staff that had taken up post on a known time - limited basis. The manager stated it had been two years since the use of agency staff had been required. It was stated by the manager that there was a shortfall of approved drivers for the company vehicles within the team. The manager assured the inspector that this did not adversely impact on service users programmes of care. Discussions with individual staff
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 23 confirmed the view that any review of the adequacy of staffing levels must take into account the variable levels of relevant skills, knowledge and experience within the team. This has a significant impact at times on service users and safety of activities inside and outside of the home. Personnel records examined identified missing statutory documentation. The manager confirmed recent instruction from the organisation’s human resources staff to managers for local responsibility for obtaining the missing documentation. Discussed was the need for a central record of all CRB Disclosures to be held in the home. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The home manager is required to make application for registration. Information verbally supplied by the manager confirmed he held relevant qualifications and had extensive experience to enable him to competently manage the home and meet its stated purpose. Quality assurance systems were in place. Whilst some working practices promoted the health and safety of service users and staff, observations identified unsafe staffing levels at night and need to review and consideration of risks relating to day and night staffing levels. A comprehensive fire safety risk must be developed. EVIDENCE: There was failure to register a manager for this home despite this being raised with the manager as far back as December 2004. The manager confirmed his imminent intention to make application for registration. The management structure comprised of a full time manager post that was 100 supernumerary to staffing levels. There was no deputy manager post within the structure. Three and halftime senior support worker posts was included to support the management of the home. An additional senior support
Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 25 worker was in post and imminently due to transfer to another home within the organisation. The inspector was informed that effort was made to rota a senior support worker on duty in the absence of the manager. The manager stated that he was a registered nurse (learning disabilities) and had attained NVQ Level 4 qualification in management. The manager and two senior support workers held the registered managers award qualification. There had been a relatively recent change of service manager and the service manager was coincidentally present throughout the second day of the inspection. He was conducting a statutory visit on behalf of the responsible individual and provided formal supervision to the manager as well as agreeing an action plan for improvements and responding to matters arising out of the inspection. Quality assurance and quality monitoring systems existed and included an annual survey of the views of relatives and advocates. Feedback from two respondents recently received indicated overall good satisfaction with service provision. An annual development plan was viewed and noted to be linked to a business plan, which was also under review. Attention was required to fire risk assessment and an action plan required to be developed relating to fire evacuation procedures and management of fire safety risks. Discussed were the details of the minor variation to be sought of the home’s registration, extending the age range of service users. Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x x Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 2 x Standard No 24 25 26 27 28 29 30
STAFFING Score 1 x x 2 x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 1 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Chelsham Lodge Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 1 x 3 x x 2 x DS0000013595.V264134.R01.S.doc Version 5.0 Page 27 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 2 Standard YA 1 YA42YA 9, 24, 42 Regulation 4(2) 6(b) 13(4)(c) 23(4) Requirement For a copy of the revised Statement of Purpose to be supplied to CSCI. For the fire safety risk risks identifying named individuals to be specified and these risks addressed in the fire safety procedures and in individual care plans. For the home to have a policy statement specific to administration of rectal Stesolid and a written protocol for administration or summoning medical emergency services. For management to ensure service users representatives have a copy of the home’s complaint procedure. For all staff to have received adult protection training. For windows in the lounge and bedrooms to have suitable blinds or curtains. An assessment of the needs of service users in
DS0000013595.V264134.R01.S.doc Timescale for action 08/12/05 12/11/05 3 YA20YA 20 10(1) 12(1)(a)(b) 12/11/05 4 YA22YA 22 22(5) 08/12/05 5 6 YA23YA 23, 32 13(6), 18(1)(a)(c)(i) 31/12/05 08/01/06 YA24YA 24 16(2)(c) Chelsham Lodge Version 5.0 Page 28 7 YA24YA 24 10(1)(a) 23(2)(b) 8 YA27YA 27 23(2)(n) 9 YA33YA 33 12(1) 13(4) 18(1)(a) 10 YA33YA 33 12(1) 13(4)(c) 18(1) 11 YA33YA 33 12(1) 13(4) (c) 18(1) bedrooms supplied only with net curtains must be carried out. To ensure arrangements are effective and responsibilities clarified for building maintenance between the landlord and registered organisation. Attention is required to ongoing problems specific to the building’s fabric and drainage. For provision of a suitable shower facility to meet the assessed needs of a named service user and ensure safe moving and handling practices. For staffing levels on night duty to be increased to provide three waking night staff pending a review of requirements and agreement wit CSCI on minimum staffing levels. For further review of night staffing levels taking into account all relevant factors and risks. Proposals for future night staffing levels must be submitted to CSCI supported by all relevant documentation for consideration and agreement on minimum staffing levels. For review of day staffing levels to ensure these are adequate to provide safe and appropriate care based on current needs assessments and review of the home’s routines and practices. The outcome of the review must be forwarded to CSCI by the specified timescale.
DS0000013595.V264134.R01.S.doc 08/12/05 08/02/06 09/11/05 01/12/05 17/02/06 Chelsham Lodge Version 5.0 Page 29 11 YA34YA 34 17(3)(b) Sch 2 12 YA34YA 34 13 YA37YA 37 14 YA37YA 37 15 YA42YA 42 For personnel records held in the home to include a recent photograph and proof of identity and documentary evidence of relevant qualification and training at the time of appointment. 19 Sch 2.7 For a central record to be maintained in the home of all Criminal Record Bureau Disclosures for staff in accordance with CRB policy guidance. 8(1)(a) For the Responsible 9(1) Individual to ensure that the home manager submits an application for registration to the CSCI. 10(1) For submission of an application for minor variation of the home’s conditions of registration to extend the age range of services accommodated to reflect current service needs. 23(4)(a)(c)(iii)(e) For a fire risk assessment to be undertaken by a person trained and competent to ensure thorough assessment of fire safety hazards. Fire safety risks and action required to manage and minimise risks must be clearly recorded. The home’s fire procedures require review to ensure evacuation, in the event of fire, of all persons in the care home and / or safe placement of service users. It is a requirement to ensure that by means of fire drills and practices at suitable intervals that persons working at the home are aware of the
DS0000013595.V264134.R01.S.doc 08/01/06 08/01/06 08/12/05 08/12/05 12/11/05 Chelsham Lodge Version 5.0 Page 30 procedures to be followed in the event of a fire. These practices must also address expectations of night workers when staffing levels are depleted. 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 YA19YA 19 Good Practice Recommendations For support workers required to cut toenails in the delivery of personal care to receive basic nail care training. It is strongly recommended that service users with specific medical conditions or other risk factors continue to receive specialist nail care input. For attention to paint splashes on ceilings, door and window frames to enhance the overall appearance of the environment. For consideration to be given to instituting a rolling programme of fitting external window blinds that can be operated from inside the home that are more suited to the home’s purpose and destructive behaviours of individual service users. 2 3 YA24YA 24 YA24YA 24 Chelsham Lodge DS0000013595.V264134.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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