Inspection on 19/12/05 for Chilworth House

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chilworth House 01/02/10

Chilworth House 18/11/09

Chilworth House 20/01/09

Chilworth House 20/05/08

Chilworth House 14/11/07

Chilworth House 15/11/06

Chilworth House 04/08/05

Chilworth House 13/01/05

Chilworth House 02/08/04

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 Chilworth House 7 Rectory Avenue High Wycombe Bucks HP13 6HN Lead Inspector Christine Sidwell Unannounced Inspection 19th December 2005 13:00 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 Chilworth House DS0000022964.V274260.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. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chilworth House Address 7 Rectory Avenue High Wycombe Bucks HP13 6HN 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) 01494 526867 01494 526140 Lloyds Scott Property Limited Jenny Brown Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Chilworth House is a care home providing personal care and accommodation for twenty-eight older people. It is privately owned. The home is situated in High Wycombe and is a short drive away from the amenities that a large town can offer. The home has been owned and operated by Lloyd Scott Healthcare since 1998 and has undergone many improvements since then. It is a wellmaintained Edwardian building and the improvements are in keeping with the style of the building. There are twenty-four single bedrooms and two double rooms, which are comfortably furnished. The home has two lounges and a pleasant conservatory. There is a sheltered outside sitting area and well-kept garden. There is an experienced staff team. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection undertaken on the 19th December 2005. The purpose of the inspection was to inspect the remaining core standards, which were not assessed at the inspection undertaken on the 4th August 2005, and to assess compliance with the requirements arising from that inspection. Policies and procedures were examined. The manager was interviewed. All residents in the home were seen and a number were spoken to. A number of care staff were also spoken to. What the service does well: What has improved since the last inspection? What they could do better: All radiators must have low surface temperatures or be protected if residents are to be protected from burns should they fall against them. The home’s staffing levels fall below that recommended by the Department of health and must be monitored closely to ensure that residents receive the care and stimulation that they need. The recruitment procedures must be improved if residents are to be fully protected from the employment of unsuitable carers. The induction and training programmes should be applied in a more systematic way if all carers are to have the skills necessary to meet resident’s needs. All staff should have manual handling training with annual updates and food hygiene training. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 6 A fire risk assessment should be completed and weekly checks of the fire alarms and the control panel should be recorded. Portable appliances should be listed and tested regularly. 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. Chilworth House DS0000022964.V274260.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 Chilworth House DS0000022964.V274260.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): 3 and 6 The home’s pre-admission processes work well and enable both staff and potential residents to assess whether the home can meet their needs. EVIDENCE: The manager said that she undertook a pre-admission assessment prior to residents moving to the home. There was evidence in the files that residents have a care management plan, which is reviewed annually. The pre-admission assessment documentation covers the areas recommended in the National Minimum Standards. Residents have the opportunity to stay for a trial period before moving to the home on a permanent basis. The home also offers respite care, which is another opportunity for some residents to assess whether home can meet their needs. Each resident has a care plan which identifies the care that they need on a daily basis. Resident’s are registered with a general practitioner and the district nursing team visit the home on a regular basis. The home does not offer intermediate care. Chilworth House DS0000022964.V274260.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): These standards were not assessed at this inspection. They were met at the inspection undertaken on the 4th August 2005. EVIDENCE: Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 10 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 The home encourages residents to remain active in the management of their affairs wherever possible. EVIDENCE: The manger said that the home does not act for residents financially. The administrative office invoices the resident or their representative for all costs. Where residents cannot act for themselves either a family member or care manager holds that responsibility. Details of local advocacy services are posted in the entrance hall. The manager said that all residents are on the electoral role and are supported if they wish to exercise that right. There is an access to records policy and the manager said that residents have access to their records if they wish. There was evidence in resident’s rooms that they are encouraged to bring their own furniture and belongings to personalise their rooms. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 11 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): These standards were not assessed at this visit. The core standards were met or almost met at the inspection undertaken on the 4th August 2005. EVIDENCE: Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 12 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 and 26 All radiators must have a low surface temperature or be covered if residents are to be protected from accidental falls and burns. The control of infection policies and procedures should protect residents from infection. EVIDENCE: It was a requirement of the last inspection that the remaining radiators were replaced by low surface temperature radiators or were covered. The radiators have not been replaced but have had a piece of plywood fretwork attached to them to protect residents from burns should they fall against them. The effectiveness of this must be monitored regularly. Most other radiators have now been covered although one in room 16 remains uncovered. This must be covered. The surface temperature was found to be 64.3C. There is a control of infection policy and staff have had training in the control of infection. Hand washing facilities are evident. There are no offensive odours. The laundry has an impermeable floor and the washing machines are capable of being run at the correct temperatures to control infection. There is a red bag system to Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 13 segregate soiled laundry. There is a clinical waste disposal contract and staff were observed to wearing protective clothing. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 14 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, 29 and 30 The home’s staffing levels fall below that recommended by the Department of Health and must be monitored closely to ensure that residents receive the care and stimulation that they need. The recruitment procedures must be improved if residents are to be fully protected from the employment of unsuitable carers. The induction and training programmes should be applied in a more systematic way if all carers are to have the skills necessary to meet resident’s needs. EVIDENCE: A staff record is kept showing numbers of staff and who are on duty at any time. The shift rotas for the last three weeks rotas showed that an average of 507 care hours are provided. This is less than recommended by the Department of Health and must be monitored carefully. There are no staff under the age of eighteen. No one under the age of twenty-one is left in charge of the home. There are sixteen carers in total. Of these four hold the National Vocational Qualification in Care at Level 2 and six are undertaking the course. The home does not yet meet the standard that 50 of staff hold this qualification, although there is a plan in place to achieve this. Six personnel files were examined to assess the thoroughness of the home’s recruitment procedures. The files were not complete and did not contain all the required documentation. All applicants had completed an application form. One form showed gaps in employment history, for which there was no written account in the file. Not all files contained copies of passports or work permits Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 15 where appropriate. All records had evidence that two references had been taken up, although it was not clear in one file whether one of the references was from the previous employer. Some but not all had a recent photograph of the employee. The recruitment policy and procedures must be updated to ensure that all the required checks are undertaken before an employee commences work. Copies of the required documentation must be kept on file. One team leader is responsible for the induction of new staff and has made a good start to this process. The induction checklists however were not complete for all staff and this must be addressed. There is an active shortcourse training programme and staff have received training in the protection of vulnerable adults, administration of medication and fire safety. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 16 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 and 38 The home ‘s management arrangements ensure that residents can have confidence that the home is being effectively managed. Overall the home’s quality assurance system should ensure that residents needs are met although this could be improved by ensuring that all requirements made following inspection are acted upon in a timely way and that administrative processes are audited on an annual basis. Residents would be better protected from potential financial anomalies if signed receipts were to be given for all transactions. The health and safety procedures do not fully protect residents or staff. EVIDENCE: The manager has more than two years experience in the care of the elderly. She holds the City and Guilds Certificate of advanced management in Care and is registered for the National Vocational Qualification in Care and Management Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 17 at level 4. She is not responsible for more that one care home. The lines of accountability in the home are clear. There is an annual development plan for the home and a number of improvements have been made in recent years. The double bedrooms are gradually being phased out and new rooms with ensuite facilities are being built. A quality assurance survey is undertaken regularly and the proprietor makes regular visits to the home. He has sent reports of these visits to the Commission for Social Care Inspection on six occasions since April 2005. His last unannounced visit was at night. This is good practice. Action is not always taken in a timely way to implement the requirements arising from inspection. The home does not manage resident’s money on their behalf. Most items are invoiced for and the account paid by the resident or their appointed person. Those residents who wish to keep their personal allowance in the home have a locked tin in their rooms and records of all transactions are kept. Not all the receipts are signed for and this must be addressed. Two tins were checked at random and the contents were found to be accurate. The residents spoken to were happy with this arrangement. There is a health and safety policy. There is a manual handling policy although not all staff had had basic training and annual updates. There is a fire safety policy. A fire risk assessment has been undertaken and is displayed in the front entrance. The last fire office’s inspection was on 29.07.04 when all fire matters were found to be satisfactory. The emergency lighting, smoke detectors and fire alarm panels were serviced in 2005. Two unannounced fire drills were held in 2005. The weekly checks of the control panel and the weekly tests of all fire alarms are recorded. The kitchen was clean and tidy on the day of the inspection and the appropriate records were being maintained. The senior carers have had food hygiene training and there are plans to introduce food hygiene training for all care staff. Annual maintenance records were seen for the lift, hoist, electrical systems and boiler. Portable equipment testing had not yet been undertaken. Risk and COSSH assessments are in place. There is an accident book in which the manager stated that all accidents were recorded. It was not possible to fully assess the water systems because of building work underway at the time of this unannounced inspection. Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 18 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x x x x x 1 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 x 2 Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 13 Requirement The remaining radiators must be guarded or have low surface temperatures by the time the central heating is switched on. This is an unmet requirement of previous reports and a new timescale has been set. The staffing levels must be monitored continually and increased if the dependency or number of residents increases. 50 of care staff should hold the National Vocational Qualification in Care at Level 2. The manager must ensure that copies of the information required by Regulation 19 Schedules 2 and 4 of the Care Homes Regulations 2001 are in every staff members file. Reports of the proprietor’s quality assurance visits to the home should be supplied to the Commission for Social Care Inspection on a monthly basis. Receipts should be given for all expenditure All staff must have manual handling training with annual DS0000022964.V274260.R01.S.doc Timescale for action 28/02/06 2 OP27 18 31/03/06 3 4 OP28 OP29 18 19 30/06/06 28/02/06 5 OP33 26 31/01/06 6 7 OP35 OP38 13 13 28/02/06 31/03/06 Chilworth House Version 5.1 Page 20 10 OP38 13 updates. The portable electrical equipment must be listed and tested regularly. 28/02/06 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 Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chilworth House DS0000022964.V274260.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!