CARE HOMES FOR OLDER PEOPLE
Chilterns End Greys Road Henley On Thames Oxfordshire RG9 1QR Lead Inspector
Delia Styles Unannounced Inspection 5th January 2006 10:30 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 Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 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. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chilterns End Address Greys Road Henley On Thames Oxfordshire RG9 1QR 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) 01491 574066 01491 574633 The Orders Of St John Care Trust Mrs Pauline Anne Krason Care Home 46 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (21), Learning disability over 65 years of age (3), Old age, not falling within any other category (46), Physical disability over 65 years of age (13) Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 46. 21st July 2005 Date of last inspection Brief Description of the Service: Chilterns End is a purpose built care home that was purchased by The Orders of St John Care Trust from Oxfordshire Social Services in the latter part of 2001. The home provides accommodation and care for a maximum of 46 older people over the age of 65, some of whom may be mentally or physically frail. The home also provides day care and respite short stays for a small number of people. The accommodation is provided in single rooms in a one-storey building. Chilterns End is set in its own grounds on the outskirts of Henley-on-Thames and is close to local health centres, shops and Townlands, the community hospital. The home has four units, each with its own kitchenette, dining and sitting rooms and there is also a large main dining room. Each unit has assisted toilets, bath and shower facilities. The building surrounds a central garden with a sensory area, planted with herbs and aromatic plants and a water feature. The garden and grounds have a range of garden seating and shaded areas, with easy access for residents from most areas of the home. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection (that is, the home was not expecting a visit) and lasted 6.5 hours. The inspector looked at a total of 11 standards, including some of the key standards not assessed during the announced inspection done in July 2005. ‘Key standards’ are the National Minimum Standards that the Commission considers should be assessed at least once every 12 months. The inspector toured the home and spoke to the home manager, a visiting senior manager from The Orders of St John Care Trust (OSJCT), the home’s administrator, care leaders and several care staff during the day. The inspector would like to thank staff and residents for their time and help with the inspection process, especially as it was a particularly busy day for staff. What the service does well: What has improved since the last inspection? What they could do better:
Though there were some improvements to the written records, the standard of care planning and records of residents’ care is still inadequate, and should be improved so that all staff have enough information to provide the correct care for residents. Care records and risk assessments should be kept up to date. The systems for the storage, handling and recording of medicines were well organised overall. A recommendation is made for staff to make some additional safeguards when making any alterations to the medicine charts after
Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 6 a doctor has ordered different medication for residents. Amounts of any unwanted or ‘no longer required’ medication should be counted and recorded before being returned to the pharmacy. Staff reported some dissatisfaction with the numbers of staff and use of agency staff, because they said that there are too few regular staff to give the continuity and standard of care they want to provide for residents. As at the last inspection, the numbers of staff just meet the levels agreed with the CSCI as being enough to provide the care needed by residents in 2002. Many of the current residents need a lot of staff assistance. Also, additional time is needed for the staff training and development. This has meant that staff find it difficult to have enough time to be involved in helping residents with activities and social events that are an important part of residents’ daily life. The manager reported that more staff are being recruited and this should improve the staffing levels. The system for keeping records of residents’ valuables that are handed over for safekeeping, and for return to residents or their representatives, should be improved by having a more detailed list of items and by using a receipt/record of valuables and property returned. The system for reporting faults or broken equipment should be improved so that residents and staff are confident that any reported problems have been dealt with and everyone knows if there is likely to be a delay in the repair or replacement of faulty items. Risk assessments should be made if temporary equipment such as free-standing room heaters are used, to ensure that the type of heater is suitable and the residents are protected from hazards such as surface temperatures being too hot and cause accidental burns, or trailing flexes that could be a trip hazard. 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. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 7 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 Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The standard of written records of residents’ care has not significantly improved since the last inspection. The care plans do not contain enough detail to provide staff with enough information to be confident that they are satisfactorily carrying out the care needed by residents. The home’s system for storing, administering and recording medicines given to residents is satisfactory overall. Some additional checks and safeguards should be put in place to reduce the risk of staff making errors when adding changes ordered by doctors to medication records and to account for the amounts of any unwanted or wasted tablets returned to the pharmacy. Residents all have their own single bedrooms. Personal support is offered in a way that promotes and protects residents’ privacy, dignity and independence. EVIDENCE: A sample of care records for five residents was inspected. The care plans still lacked sufficient detail and updating. For example, a resident admitted for a short respite care stay had no care plans written or clear instructions about family contact information should this be needed during their stay; this person had very limited sight and a particular physical healthcare need. Another
Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 10 resident had no care plans describing the care measures staff should try that had been suggested by a visiting mental health nurse. There is an expectation that staff review care plans at least monthly, to check that they are still up to date and that the written instructions about care are accurate to give staff enough information about how to meet the needs of the residents. This is particularly important where agency staffing is used by the home to cover the home’s staff absence and sick leave. The medication administration records (MAR) and medicine storage system was looked at. There was evidence of a consistent and safe system in place to make sure that residents’ receive their prescribed medication. Some handwritten alterations to MAR sheets had not been signed by the doctor or the carer who wrote them (on the doctor’s instructions). It is good practice for the doctor to check and sign any changes made to residents’ medicines. If the doctor is not available to do this as soon as possible, a second carer should check and countersign the changes, to lessen the risk of mistakes. The home returns unwanted, wasted, or unused medication to the pharmacy. It is recommended that the number and description of tablets or medicine for disposal is recorded and signed by the responsible care leader, so that there is a way of accounting for medicine ‘returns’. Most staff have completed a distance-learning course in safe handling of medication and 16 were undertaking training provided by a high street chemist. The home should keep a current list of the names, signatures and initials of all staff authorised to administer medication. Residents’ accommodation is in single rooms. Staff were seen to knock on room doors and await the resident’s response before going into their room. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents’ views are sought about the way in which they want to be cared for and how they spend their time and they are encouraged to make choices and have control over their lives as far as possible. EVIDENCE: There was evidence that the home’s staff have a good understanding of residents’ care needs and their likes and dislikes. Residents and staff evidently have a good rapport. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has regular training for staff and written information about how to report any suspected abuse of residents. EVIDENCE: New staff attend training on adult protection issues during their induction to the home and all staff have a mandatory annual update. All new staff receive a copy of part of the Oxfordshire Multi-Agency Codes of Practice for the Protection of all Vulnerable Adults. There was evidence that the manager and staff are aware and take appropriate action to safeguard residents who may be at additional risk because of their mental frailty. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 The standard of the indoor and outdoor environment of this home is good providing residents with an attractive and homely place to live. There is evidence of regular maintenance reviews and future planning to maintain and improve facilities for residents. EVIDENCE: The standard of cleanliness and décor is very high overall. There is evidence of forward planning for any improvements, such as re-carpeting the lounge and corridor leading into Hambledon unit. Worn kitchen units in the kitchenette areas for each wing are also said to be scheduled for replacement and upgrading: this work is outstanding from three previous inspection visits but the manager said that the budget has been agreed and hoped the work will be carried out soon. One resident complained that s/he was cold in the sitting room, and in particular, his or her own room. The temperature in the sitting room was satisfactory at 21°C but the resident’s own room was cold - the room temperature was below 18°C - because the room radiator was not working. A
Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 14 carer said she believed that a new part had been ordered for the radiator. If a temporary free-standing room heater is used, there should be a risk assessment done to make sure the resident is protected from hazards such as a heater surface that becomes too hot, or trailing electrical flex. This was discussed with the home administrator and the maintenance man was asked to attend to the radiator and also check that a water leak under the bath in Room 118 was seen to as soon as possible. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 28 Staff morale has deteriorated because of high levels of sickness and increased use of agency staff, which staff feel is having a detrimental effect on the standard and consistency of care they offer. The training programme for staff shows that the organisation is committed to helping staff to develop their skills and competence in their jobs. EVIDENCE: Staffing levels and skill mix are being maintained at the levels agreed when the home registered with the Commission. Some staff expressed concerns about the drop in staff morale that they felt was caused by recent high levels of staff sickness, some ‘unreliable’ staff, and use of agency staff some of whom did not know the residents’ needs well. This put additional pressure on existing staff members and in their opinion, undermined the standard of care for residents. The manager said that she was in the process of meeting with all the care staff to discuss their concerns and was actively recruiting new staff so that there will be enough of the home’s own staff to lessen the use of agency staff and to provide extra time for staff for training and study days. The OSJCT has a central training co-ordinator who is implementing a programme of training and development for all Oxfordshire OSJCT homes. Two care staff are undertaking NVQ Level 3 and four are undertaking NVQ
Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 16 Level 2 training. An OSJCT NVQ assessor was working with some of the NVQ candidates on the day of the inspection. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 36 The manager has considerable experience in caring for older people and provides clear leadership throughout the home. She communicates effectively with residents, staff and relatives. Residents’ views are sought from time to time and there is evidence that they do influence the way in which the home is run. The systems in place for safeguarding residents’ personal allowances and property are sound overall. The programme for regular formal supervision meetings with all care staff is in place, though more work is needed to make sure that supervisors and supervisees are confident about the purpose and benefit of supervision and that it is a regular planned part of staff’s work time. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 18 EVIDENCE: Mrs Krason has extensive experience in administration and care in care homes for older people. She has worked in assistant manager posts in care homes in Oxfordshire run by Oxfordshire County Council and then The Orders of St John Care Trust. She is currently working towards her Registered Manager’s Award and N.V.Q in Care Level 4. She became the registered manager for this home in October 2005. She demonstrated a calm and competent approach when dealing with unexpected events on the day of the inspection: these included a resident going missing from the home, necessitating putting into action the home’s procedure for searching for missing residents and liaison with the police (the resident was found safe and well at their family home nearby). As part of the OSJCT quality assurance programme, residents and relatives are sent questionnaires about the home’s services and facilities. There was a ‘satisfaction survey’ about the catering and meals available in the front reception area. OSJCT employs a quality assurance manager who analyses the quality surveys and any complaints so that action can be taken to make improvements where necessary. There are internal staff and residents’ meetings and review meetings to encourage the participation of residents in decisions relating to the home and their care. There were copies of a Residents newsletter (January – March 2006) and The Orders of St John Care Trust (OSJCT) winter magazine available in the entrance hall and lounges. A residents’ meeting is to be held on January 9th at which residents are invited to ‘air any problems, issues or complements’. Mrs Krason said that she has an ‘open door’ policy for residents, their relatives, and staff so that any problems or complaints can be discussed and dealt with promptly as soon as they arise. The system for accounting for any small amounts of residents’ personal allowances held on residents’ behalf is common to all OSJCT homes. Residents’ allowances are paid weekly into a pooled bank account. The administrator maintains an accounts system that enables deposits and withdrawals made on behalf of each individual to be identified. A petty cash ‘float’ is kept in the safe, so that residents can have access to their allowance on request. A record is kept by the administrator of any small items of value kept for safekeeping at the request of residents. It was recommended that improvement is made to the way in which staff record the receipt and return of valuables to residents or their representatives. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 19 The manager said that a new timetable for formal staff supervision sessions was in place and that they have improved on having regular supervision times with care staff, though this needed to be done more frequently to meet the recommended frequency of 6 times a year. New ‘supervision contracts’ have been produced, and care leaders will take on the supervision of care staff. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 20 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X 3 X STAFFING Standard No Score 27 2 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X X Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 21 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Improve the written records of residents care - the care plans - so that there is sufficient detail about their care needs, (including social and recreational needs) and the actions staff need to take to meet those needs, and to record to what extent the care plan has been successful (evaluation). Care plans should be reviewed at least every month and rewritten if residents’ care needs change significantly. Residents nutritional status should be assessed on admission and regularly reviewed, using a recognised assessment tool: the Malnutrition Universal Screening Tool (MUST) is recommended. * Any handwritten additions or amendments to the MAR sheets should be checked and signed by the doctor who ordered the change. Or the staff member who has written the amendment should sign their entry and have a second staff member check and countersign. * An up to date list of the care staff authorised to give
DS0000013154.V276213.R01.S.doc Version 5.1 Page 22 2. OP9 Chilterns End 3. 4. OP25 OP27 5. OP35 6. OP36 medications should be kept, together with a sample of their signature and initials used when signing the MAR sheets. * A record should be made of the type and number of any unwanted or wasted tablets and medicines to be returned to the pharmacist for safe disposal. Ensure prompt repair of faulty room radiator(s) and undertake a risk assessment for any freestanding room heaters if used temporarily. Ensure that the number and skill mix of staff meets the assessed needs of residents at all times. Staffing levels should allow for the additional time needed for training and supervision of all staff. Improve the system for records of valuables or property held for safe keeping and returns to the resident or their representative by using a simple carbon copy, one to be retained by the home. The designation and signature of the staff member receiving and handing back property should be listed. Implement the programme of formal supervision so that all staff have the recommended number and frequency of sessions. Chilterns End DS0000013154.V276213.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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