Inspection on 21/01/08 for Cheybassa Lodge

This inspection was carried out on 21st January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Cheybassa Lodge 09/12/08

Cheybassa Lodge 04/07/07

Cheybassa Lodge 14/08/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Cheybassa Lodge 2 Chichester Avenue Hayling Island Hants PO11 9EZ Lead Inspector Annie Taggart Unannounced Inspection 21st January 2008 11:00 X10015.doc Version 1.40 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 Cheybassa Lodge DS0000066613.V356480.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 Older People. 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. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheybassa Lodge Address 2 Chichester Avenue Hayling Island Hants PO11 9EZ 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) 023 9246 2515 Mrs Lesley Pamela Quinton Mr Michael Quinton Mrs Lesley Pamela Quinton Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2007 Brief Description of the Service: Cheybassa Lodge is a large detached property located on the seafront on Hayling island, Hampshire. The communal lounge overlooks the seafront and promenade with large windows to provide everyone with wonderful views. The front garden also proves very popular with service users during the summer months when various carnivals, processions and sea events take place. Ample car parking facilities are to the side of the home. All service user accommodation is located on the ground floor, making access easier for service users, whilst the proprietors live upstairs. The home is currently registered to provide care for 18 adults in the older person category and consists of six single bedrooms and six double bedrooms, all with en-suite facilities. The fees for the home range from £337.00 to £500.00 per week. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. In order to prepare for the visit, surveys were sent to families, the people living in the home and other professionals involved with the home. Seven service user, one professional and four family surveys were returned and most commented on improvements to the service being provided by the home. Two family members also telephoned the Commission to give their feedback regarding the surveys. An Annual Quality Assurance (AQAA) had been completed by the home following the last inspection visit and information from this and the last two inspection reports was also used to inform this report. The unannounced visit was carried out at 11am and lasted for four and a half hours. During that time we spoke to two people visiting their relatives, we spent time with the people living in the home, both in their bedrooms and in communal areas and we spoke to the staff on duty and observed staff practice. Four care plans and all supporting documentation such as daily records were looked at and we also looked at the system for the recording and administration of medication. We looked at five staff records and all contained the required documentation and we also saw evidence of staff training and development. During the visit we looked at food records and saw lunch being prepared and served and we asked people what choice they had in the meals that are provided. Records for the running of the business including the quality assurance process, health and safety and incident and accident recording were seen. The Registered Manager is also one of the Registered Providers. Both Registered Providers were present and received feedback following the visit. Cheybassa Lodge DS0000066613.V356480.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: Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 7 Although there have been many improvements made to the home, to ensure that service users are kept comfortable and safe at all times the Registered Manager must ensure that: The home is kept at a comfortable and warm temperature at all times so that service users are not complaining of being cold. Any incident that adversely affects the well being of service users, such as falls in which people are injured should be reported to the Commission. To ensure that the people living in the home are kept safe, once thermostatic valves are fitted to hot water outlets, the temperature of hot water in bedrooms should be regularly checked and recorded. 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. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 and 6 Outcomes for service users in this area are good. This judgement has been made using available evidence including a visit to this service. The process for admitting new service users has been improved, good preadmission assessments are carried out, people can visit the home or choose to have short stays before moving in. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place and people confirmed that they were given a copy when making enquiries about the home. We saw the records for two recently admitted service users and for both a comprehensive pre-admission assessment had been carried out prior to them moving to the home. People confirmed that they were encouraged to visit the home or come for short respite stays before making a decision about whether to move in. Contracts of terms and conditions of residence are now in place and these include the fees to be paid. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 10 Cheybassa does not provide intermediate care. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Outcomes for service users in this area are good This judgement has been made using available evidence including a visit to this service. There have been improvements to care plans and people are receiving good healthcare support. EVIDENCE: For each person living in the home there is now a plan of care in place detailing both the personal care and healthcare support that people require. We tracked five care plans and all included personal details such as next of kin and preferred lifestyle choices and also contained risk assessments including risk of falls. All plans had recently been reviewed. Records show that people have access to other professionals such as Chiropodist and District Nurses and in a survey a local Doctor who regularly Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 12 visits the home said that he was confident that people’s healthcare needs were being met. Although regular reviews and daily records are in place, sometimes they just say “no change” or “ all care given”, which does not fully describe what care was actually received. The manager said that she would discuss improved recording methods with the staff team at the next staff meeting. There is a monitored dose system of medication in use and a list of authorised medication handlers is also in place. Medication was suitable stored and records were current and in good order. The people living in the home said that they were treated with dignity and respect and comments included, “ We are well cared for and the staff are very kind” Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Outcomes for service users in this area are excellent. This judgement has been made using available evidence including a visit to this service. The home provides a wide variety of activities, outings and community involvement for the people living there, visitors are made welcome and people receive a choice of fresh, home cooked meals. EVIDENCE: The home excels in the amount of activities, outings and opportunities for community involvement it provides for the people who live there. In good weather people go out to the beach, local garden centres for tea and also go to the local shops. Entertainers visit the home and there are good links with local churches and clubs. People are involved in the running of the home and we saw people setting and clearing tables, helping to dry dishes and during the visit several people were knitting blankets for an oversees charity. Comments included. “There are lots of games and activities like making music, quiz’s and outings There is always someone here at night, they always come if I ring the bell and will make me a cup of tea” and “in the nice weather we go to the beach, out and about in the minibus and I also go to the local Baptist Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 14 church with my daughter. I have all my own bits and pieces and photos of my family about me. The food is nice and they will always make you an alternative”. A visitor commented, “I find the home delightful and very friendly and whenever I visit I am offered refreshments and invited to stay for a meal”. Menus show that people are offered a variety of fresh, home cooked meals and people were complimentary about the standard of food provided. We saw lunch, the main meal of the day being prepared and served, fresh ingredients were used and the meal was attractively presented. The menus currently only show the main meal of the day, the cook told us that menus are currently being revised with input from service users and that breakfasts and suppers will be included. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies, procedures and working practices are designed to protect people from risk of abuse and complaints are taken seriously. EVIDENCE: The home has a complaints procedure a copy of which is included in the Service User Guide and also displayed in the home. The people living in the home and a visitor said that they would feel confident in making a complaint, one person said, “ I feel confident that if I did have a complaint, it would be taken seriously if I approached the manager”. No formal complaints have been recorded in the past year. There are policies and procedures in place regarding the protection of people from abuse. The staff members on duty were aware of their responsibilities and said that they would report any suspected abuse straight away. Most staff have attended training in adult protection and the manager said that she was going to attend the new Safeguarding training and cascade this to the staff team. A Requirement made at the last visit regarding risk to service users by some Criminal Bureau Checks (CRB) not being in place has now been met. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 16 Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 24 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home is attractive, homely and clean, there are risks to service users by hot water temperatures not being recorded, some water outlets being too hot for safety and the home not providing sufficient heating. EVIDENCE: The home has carried out extensive improvements to the environment and a programme of redecoration and refurbishment is still underway. All bedrooms are being redecorated and some have new furniture and carpets in place. A new kitchen has been fitted in the past year and a new bathroom with assisted bath has also been purchased. All radiators in bedrooms have now been covered to ensure that people are Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 18 not scalded and heated towel rails are being fitted in ensuite bathrooms. Although basic scalding risk assessments are in place for the towel rails, as they are not covered, the surface temperature needed to keep people safe does not keep the bathrooms warm. One person said that even with the towel rails in place, it was very cold in their bathroom at night. The home was very clean and homely throughout. A number of people said that they were very happy with the facilities provided and in a survey a family member said, “ I couldn’t ask for better care for my Mum, it meets all her needs. Mum has a telephone in her room and I can visit and take her out whenever I like, My mum gets lots of help and support, which is what I would expect and what was agreed when she went into the care home”. A visitor said, “As the home is all on one level there is easy access and it is always clean and comfortable with no bad smells”. In three bedrooms that we tested we found that the hot water in ensuite sinks was at a temperature that was too hot and was a scalding risk. There were no records in place of regular testing of water temperatures. The Provider then checked other sinks and found them also to be very hot. The provider and manager immediately made the sinks safe and called a plumber. The Provider then telephoned the Commission the next day to say that all sinks would be fitted with thermostatic controls and that the work would begin on 24/1/08. In two family surveys and in discussion with the people living in the home, in all five people commented that the home is often not warm enough. During a tour of the building to speak to service users we noticed that communal areas such as corridors and some bedrooms were cold and in one room we brought to the attention of the manager that one person, who despite having a rug around their legs, was cold to the touch and complaining of being cold. The manager said that the home was having difficulties in gauging the correct heat for rooms after recently having radiator covers fitted and she immediately increased the level of heat in the home. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty to meet the needs of the people currently living in the home. People are now being protected by the home’s recruitment procedures and staff receive training and support. EVIDENCE: The staffing rotas show that there are sufficient numbers of staff on duty to meet the needs of the people currently living in the home. A Requirement made at the last visit for the hours people work to be included in the rotas has been met. The people living in the home were very complimentary about the staff team and said they were kind and caring. Observation during the visit showed that there was a friendly, open and supportive atmosphere in the home. During the past year seven staff have completed NVQ 2 in Care and have now begun NVQ 3. Other staff have also now started on NVQ 2 and records show that a Requirement for staff to receive dementia training in order that they might better meet the mental healthcare and emotional needs of people has now been met. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 20 The manager showed us a case study carried out by the local college used by the home in which the manager was commended for her commitment to staff training. We looked at the recruitment records for five staff; including those most recently employed and all contained the required documentation including a current CRB and two references. The manager is currently updating the home’s application forms to include a full employment history. Formal supervision is still not in place but the manager said that as it is a small team and she works alongside people on a daily basis, informal supervision is carried out from day to day, the manager also showed us staff meeting records that gave evidence that during the meetings she provides in-house training sessions and showed that care practice issues are also discussed. Mrs.Quinton said that she would record all supervision and in-house training sessions in future. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 and 38 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 quality assurance process in place and people are complimentary about the way the home is managed. However there are still areas of risks to service users that have not yet been fully addressed. EVIDENCE: The manager of the home, Mrs Quinton is also one of the Registered Providers. She has completed NVQ 4 and said that she also carried out further training in order to keep her registered nurse’s qualification up to date. Both the people living in the home and families were complimentary about the way the home is managed and described the manager as open, friendly and Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 22 accessible. A staff member said, “ The new manager is very caring person and make me feel valued as a team member”. There is good evidence that the manager has worked very hard to meet the Requirements made at the last two visits and a number of improvements have been made to standards in the home. During the past year a quality assurance process has been carried out by the home sending surveys to service users, families and other professional. We saw the returned surveys and the manager said that the outcomes would be collated and used to inform the future development of the home. We saw the accident and incident book and confirmed that accidents are recorded and are linked to daily records for service users. However there was no evidence that medical advice had been sought following a fall that had caused bruising to a service user and this was not reported to the Commission as required by Regulation 37 of the Care Homes Standards Act. Mrs Quinton said that she would ensure that this would be done in the future. Records for the running of the business including staff records, care plans and pre-admission assessments have been improved but there are still health and safety issues such as the heating in the home that needs to be addressed. Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x 2 2 Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 24 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 OP25 Regulation 23 (2) (p) Requirement The Registered Manager must ensure that people’s personal and emotional healthcare is protected by the home being warm in cold weather and that the temperature in bedrooms is at a level to suits individual people’s needs at all times. The Registered Manager must ensure that all incidents such as falls that cause injury to service users are reported to the Commission as required by Regulation 37 of the Care Standards Act. Timescale for action 01/03/08 2 OP37 37 (1) (e) 01/03/08 Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cheybassa Lodge DS0000066613.V356480.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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