Inspection on 06/06/07 for Chippendayle Lodge.

This inspection was carried out on 6th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Chippendayle Lodge. 18/05/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Chippendayle Lodge 10 Chippendayle Drive Harrietsham Maidstone Kent ME17 1AD Lead Inspector Eamonn Kelly Key Unannounced Inspection 10:30 6th June 2007 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 Chippendayle Lodge DS0000067120.V340256.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. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chippendayle Lodge Address 10 Chippendayle Drive Harrietsham Maidstone Kent ME17 1AD 01622 859230 01622 859230 sandra@charinghealthcare.co.uk 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) Charing Dale Ltd Ms Sandra Pearce-Tamsett Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 6 people with a diagnosis of dementia can be accommodated. 18th May 2006 Date of last inspection Brief Description of the Service: The home provides accommodation and care for up to 21 older people. Charing Healthcare Ltd owns and operates the premises. All residents have single bedrooms. Most bedrooms have en-suite facilities. There is a shaft lift between the two floors. Village amenities are nearby as is public transport. Weekly fees are as follows 1. Privately funded residents: Residential £490-£525. Dementia care: £510£550. 2. Local Authority funded residents: £390-£410. Additional charges are made for chiropody, hairdressing, £7.50 TV licence, private telephones, and newspapers. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 6th June 2007. It consisted of meeting with residents, the manager of the home and members of staff. Support practices were observed and discussed with members of staff. A variety of records was seen during the visit principally those that supported the care of residents. The manager submitted a completed AQAA (annual quality assurance assessment) to the commission. This was helpful in the preparation of this report. The report contains information about progress made since the previous inspection visit and about how further improvement is necessary for the welfare and comfort of residents. The manager has addressed the requirements contained in the previous inspection report and has given appropriate consideration to the recommendations. This report contains requirements relating to the need for clearer written preadmission information, better arrangements for helping residents remain physically and mentally alert, appropriate staffing arrangements and provision of relevant training that helps staff meet the specialist needs of residents. What the service does well: What has improved since the last inspection? The requirements in the previous report have been addressed. Pre-admission information has improved. Better medication procedures have been adopted and associated equipment purchased. Plan care plan records have been introduced and this improvement is continuing. New WC frames have been bought. Staff have been enrolled to undertake NVQ Level 2 in Care. Residents have a better variety of meals. Some risks of cross infection have diminished. Fire safety procedures have been improved. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 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 Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6. Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. Prospective residents and their advocates receive assistance when they are first considering the option of residential care. This support would be improved if services and facilities were accurately described in the pre-admission guide. EVIDENCE: Prospective residents and their supporters have access to a variety of documents (service user’s guide, statement of purpose, glossy leaflets) about the home. The information is confusing, duplicated and, in some cases, misleading. Clearer information is more likely to give prospective residents and their supporters a better guide to facilities and services. This would, for example, clearly indicate the qualifications and mandatory training undertaken by staff, support provided for helping residents to remain more physically and mentally alert and show the measurements of bedrooms (net of en-suite Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 9 sizes). The format should be as outlined in Schedule 1 of care home regulations. Prospective residents are assessed before admission and are invited to visit, meet staff and other residents, have a meal and look around. A care plan record is begun when agreement is reached on admission. Receipt of a copy of an accurate and informative Residents’ Guide is important at this stage. Respite care is offered when a room is available. The previous inspection report referred to residents saying that this was how they had originally been introduced to longer-term residential care. Residents spoke of the support and assistance they had received in helping them to settle in. Recuperative care is not a part of services offered. A personal contract is provided to all residents. All new residents, it is understood, receive an offer letter undertaking to meet their specific assessed support. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 10 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, 10. Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. Residents receive good personal and healthcare support. EVIDENCE: Care plan records contain reasonably good information about residents’ care needs and how these are being met. Improvements or deterioration in their health or disposition is recorded on a daily basis. At staff changeover, these conditions are briefly discussed for the benefit of staff arriving for the new shift. The information about residents’ background is variable. In some cases now, the information is not as accurate and up-to-date as would be expected. Care plan records should contain a typed resident’s profile completed by staff and contributed to by residents and their advocates. Nevertheless, members of staff have a good understanding of residents’ general background, care needs and how these are being addressed. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 11 The owning company’s risk assessment procedure is being implemented for all residents [in relation to premises and personal risks (eg. falls, medication allergies, personal fears/mental health difficulties)]. The examples seen were not as comprehensive as might be expected. Members of staff continue to use a communication book and handover procedure to better enable continuity of care. Care records show continuing good liaison with health and social care agencies. The previous report indicated problems with the provision of food. Since then an experienced and qualified chef has been appointed. Although all residents received exactly the same lunch and dessert, they expressed satisfaction and the chef said that residents are asked the previous day to choose their main meal. Later during the inspection visit, staff prepared the evening meal: residents have choices and a heated component to the meal. Continuing improvements have been made to the medication procedure (medication trolley and fridge purchased, 28 day medicines have date recorded on tube/bottle, medicines given PRN identified in MAR sheets). A carer administering medication queried with the manager two instances where she thought clarification was needed. It is understood no controlled drugs are currently stored at the premises. The manager says that no staff who have not undertaken the “Safe Handling of Medicines” course administer medicines. Residents are treated with great respect and always with consideration for their physical and psychological needs, dignity and privacy. Toilet and bathroom doors are lockable. Residents can make and receive phone calls in private. Some have private phones in their bedrooms. Members of staff do not open letters unless there is a recorded agreement for this to happen. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 12 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): 12-15. Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to the service. Residents are helped to enjoy a good lifestyle but better access to a range of activities would keep them more physically and mentally alert. EVIDENCE: A number of residents buy newspapers and read these in the lounge or bedroom. TV reception is poor in most bedrooms: in some cases two channels only could be viewed without difficulty. A resident has purchased a Freeview converter to address this problem on a personal basis. In several bedrooms clocks show the wrong time. Members of staff say they will keep an eye on this in future to assist residents. Bedroom doors have miniature door numbers that are difficult to read: it is understood large door numbers will soon replace these and this will assist residents. Two residents referred to a befriending scheme run by a group of local people. This helps some residents to have occasional coffee mornings in the village. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 13 Members of staff say that they provide occasional passive exercise sessions. Once a month there is a visiting entertainer. Some residents say they are concerned about the planned extension (linking the empty bungalow with the home) and a probable further extension. This, some say, would reduce the garden amenity that they currently highly value and appreciate. In the response to the draft report, the area manager said that these worries are without any real foundation. Some residents receive assistance from local church volunteers. A hairdresser uses the area at the end of the lounge (during the inspection an empty bedroom was used for this purpose). Good contact and support is promoted with family and friends. The home has effective working relationship with local health and social care professionals. Reviews with care managers take place regularly. The owning company’s quality assurance report suggests full satisfaction by residents and others of all aspects of life at the home. An external review (i.e. commission inspection) suggests otherwise. Residents expressed admiration of the efforts of the manager and all members of staff. Some said that they have come to accept the pressures on staff as they have to carry out most household activities and staff numbers are low. Some said that life was as good as can be expected but that hours are long, sitting in their bedroom or in the lounge. They referred to the activities arranged and said that although these are very occasional they are nevertheless welcome. An experienced and qualified chef has been appointed. This has led to improvements in the range and quality of food provided although all residents were provided with exactly the same mid-day meal. Please see the previous section of this report. Unusually for a home registered to accommodate people with dementia, no activity co-ordinators are employed. There is a perception that residents prefer current informal arrangements and might resent a more organised and consistent approach. Many residents have dementia, others are experiencing the distressing on-set of dementia. Some have significant levels of depression. Some are regarded formally as “EMI”. Many need significant assistance because of their deteriorating physical conditions and sensory loss. During the inspection visit, residents were left alone for long periods in the morning and again in the afternoon. They have to make do with the situation and have become, to an extent, conditioned. A resident said that if you cannot read, life is quite tedious. Some coped well, others spent long hours sleeping in their chairs. It was agreed with the manager (later confirmed by phone with an area manager) that the services of an activities organiser would be appropriate. This would provide dedicated and professional support for residents to remain more physically and mentally alert. Care staff could also repeat some of the Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 14 activities when the activities organiser was not present. As a general guide, one hour per week per resident should be in place. Therefore, at least 21 hours per week is expected. Chippendayle Lodge DS0000067120.V340256.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): 16,18. Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. Protection from abuse is promoted through following general policies procedures, staff training and understanding of the actions staff may need to take in all circumstances. Some residents are prepared to make their views known. EVIDENCE: A complaints procedure is available to residents and their supporters. CSCI questionnaires returned by residents and relatives of residents did not refer to any particular concerns. However, staff generally completed these and the evidence is that residents were not encouraged to make comments in the free text areas. Two of the three staff files indicated that staff have not received sufficient training in POVA (protection of vulnerable adults) but the manager is arranging such training for all members of staff. In her response to the draft report, the area manager said that this training was given on 19 June 2007. Recruitment practices are such that the required range of checks (including CRB’s) is carried out for all new and existing staff. The manager is aware of local authority Safeguarding Adults procedures. She says that a definite Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 16 strength of the current approach is that agency staff is not used so residents always have someone they knew personally to care for them as a further safeguard. There were no complaints since the previous inspection. Charing Healthcare Ltd carries out annual quality assurance monitoring. The current report suggested that residents are very happy with all aspects of life. The report is used by the manager and area manager to assess how the home is performing and if improvements are necessary. Chippendayle Lodge DS0000067120.V340256.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, 20, 26. Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. Residents have the benefit of living in comfortable premises. EVIDENCE: Residents’ bedrooms are suitable for purpose although some are fairly small. The sizes of bedrooms (excluding en-suite) will be included in a new Residents’ Guide. Most have en-suite facilities. At least one resident has an electrically operated bed. There are good garden facilities that residents value and appreciate. Some were concerned that this garden facility might be lost or significantly diminished because of a further planned extension. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 18 Parts of the premises are a little run-down. However a new maintenance person has been appointed for about 20 hours a week and this will, according to the manager, be of great assistance for day-to-day maintenance. Residents have the benefit of a shaft lift (a stair lift is available but is currently not in operation). The nearby bungalow is to be refurbished and added to the care home premises as additional bedrooms. This is likely to be an opportunity for a sluicing facility to be installed and essential maintenance to be carried out. Residents have use of a lounge and conservatory. Two WC’s are close to the lounge/dining area and this is useful for residents. Different style chairs give a choice of seating. Some bedrooms have doors opening to the garden. A resident who uses an electrically operated chair says he would not be able to get out of the chair without this aid. Apart from the bath hoist, no other hoists are used or available. Most residents use the ground floor bathroom that has a parker bath (the shower was not working properly and needs repair). One resident uses the 1st floor bathroom almost exclusively. Toilet frames have been bought and will soon be fixed to floors in en-suites and bathrooms for added safety of residents. All radiators are covered and hot water outlets are fitted with thermo controls to protect against scalding. Chippendayle Lodge DS0000067120.V340256.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, 30. Quality in this outcome area is adequate. This judgement was made using available evidence including a visit to the service. Members of staff are hardworking and enthusiastic but residents and members of staff would benefit from better staff training. The significant support needs (including dementia care) of residents require that sufficient numbers of trained members of staff be on duty to address these needs. EVIDENCE: During the morning shift, three carers were in duty. This falls to 2 in the afternoon shift (with a additional carer on duty between 5-8pm). Since receipt of the draft inspection report, the company’s area manager has intervened to increase the afternoon staffing level to 3. During this inspection visit, a chef and a domestic worker were also on duty. At night, 2 carers (awake) are on the premises. The evidence of the inspection was that there is an inadequate number of staff on duty to cater effectively for the levels of need and disability. There is no activity co-ordinator. Members of staff say they help to maintain residents’ mental and physical alertness. This issue is included earlier in this report. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 20 Staff are hardworking, enthusiastic and knowledgeable about residents’ needs. In one instance, a carer looked very closely at aspects of medication administration and referred concerns to the manager. This good practice is of benefit to residents. Staff files suggest good recruitment checks are undertaken. The manager maintains a list of the names of all staff together with their CRB reference number, the date of the check and a brief reference to the outcome (particularly where any information in the CRB check is regarded as not relevant). The manager carries out staff supervision every 4-6 weeks the outcomes of which is recorded. The lack of adequate support and training might probably have been identified and addressed earlier. However, the policies and procedures of the new company take time to be fully understood. Two of the three staff files indicated that members of staff receive inadequate training. Some members of staff receive no training in moving and lifting vulnerable people. The training others receive in this skill, according to the training schedule, is theoretical rather than practical. The training schedule for infection control was more seminar attendance and general than detailed and job relevant that required further thought and reflection by staff. The required level of “mandatory” training is not present although current pre-admission documents given to prospective residents claim it to be. The manager was advised to liaise with local colleges and to obtain a partnership agreement to arrange relevant training for all staff. This contact can lead to RVQ and NCFE being obtained under colleges training grants. It is acknowledged that the manager is arranging for 6 members of staff to undertake NVQ Level 2 in Care as the basic care qualification. Some of the training provision required at the previous inspection remains outstanding (Fire Safety and H&S, Moving and Lifting and subsequent annual updates). Based on observation of medication administration skills, training received by staff is effective. The manager is aware that training provision is an important part of supporting members of staff care properly for residents.. A discussion took place during the inspection visit about the need for the registered manager to be responsible for ensuring that members of staff receive relevant and substantive training. The broad outline discussed during the inspection was as follows: • • • • Registered Manager’s Award. For managers, deputy managers. RVQ Certificate in Dementia Care. For all care staff working with people who have dementia or with the on-set of dementia. NVQ Level 2 in Care. For all care staff. Level 3 should be available for senior staff and carers who wish to progress their skills. Food & Hygiene: All staff must have food hygiene training. (eg. 1-day by DS0000067120.V340256.R01.S.doc Version 5.2 Page 21 Chippendayle Lodge the Borough Council. Lasts for 2 years). However, the better option for all staff is “Food & Nutrition”. • NCFE Certificate in Nutrition & Nutrition. For kitchen staff and carers. • NVQ Level 1 in COSHH. For domestic staff. • NVQ Level 2 in Domestic Cleaning. For domestic staff. • Certificate in Safe Movement of Vulnerable People (Manual Handling): Valid for 5 years. Annual half-day updates. For all staff. • NCFE Certificate in Occupational Health & Safety. For care staff. • NCFE Certificate in Infection Control. (a) Infection Control. Valid for 3 years. This relates to the law, who to report to, contamination etc. to, contamination etc. (b) Cross Infection: This is about bodily fluids, disposal of materials, laundry etc. Staff should preferably receive training in infection control and cross infection. • Fire Training: In-house by reputable company. At induction. And for all staff every 6 months. • Skills for Care Level Induction. For all staff. • Staff Supervision & Appraisal. Staff undertaking supervision. • Fire Training: In-house by reputable company. At induction. And for all staff every 6 months. • Adult Protection/POVA: Updates to be provided in-house as legislation and/or NMS/regulations require. For all staff. • First Aid: (a) Senior Carers: 3-day course and (b) Carers: 1-day course. Renewable after 3 years. All shifts should include a first-aid trained person. • Health & Safety: Valid for 3 years. Refresher as and when legislation changes. For all staff. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 22 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, 38. Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. Residents have the benefit of living in a residential home that is well conducted. They would benefit further if there were sufficient numbers of trained staff on duty and if all staff receive relevant and specialist training. EVIDENCE: The manager, Sandra Pearce-Tamsett, has significant experience in supporting residents in residential care settings. She plans to soon undertake the RMA (Registered Manager’s Award). Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 23 There was a positive atmosphere during the inspection visit. Staff and residents spoke directly about procedures and routines. Staff demonstrated a definite empathy and understanding towards the challenges faced by residents. Residents say that the home is run in their best interests and they spoke highly of the efforts of the manager and other staff. There are policies in place for the required aspects of supporting people in residential care; the manager has made good progress in meeting previous CSCI requirements and has indicated that she will address requirements following this inspection. Residents’ interests are protected with families dealing with their finances. The manager holds small amounts of petty cash on behalf of residents and keeps records where additional charges are made. The AQAA (annual quality assurance assessment) submitted to the commission declares that all safety certificates and associated records are in place. The manager has successfully addressed the requirements in the previous inspection report and good consideration is being given to the recommendations contained in that report. This is a good indication that quality assurance measures are in place. The registered responsible person supports the manager through monthly visits and reports: these reports were not reviewed on this occasion. Elsewhere in this report, attention has been drawn to the need for increased staffing so that the correct staff “mix” is available. The services of an activities organiser are required, for direct impact and motivation of staff on each shift. Since the inspection, the manager and area manager have taken steps to address these concerns. Prospective residents and their supporters need more accurate information at the stage they are considering the option of residential care. The manager is assuming full responsibility for staff training and arranging for all relevant training to be arranged. These improvements are necessary for the benefit of staff and residents, particularly as some residents have dementia or on-set of dementia. The declarations made in the 2007 AQAA (annual quality assurance assessment) are helpful but the rate of improvement on staff training is not consistent with the claims made in materials given to prospective and existing residents. The commission is confident that suitable acceleration in this respect will be made. Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 24 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 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1OP1 Regulation 4, 5, 6. Requirement Written pre-admission information must be clearer and claims made about services and facilities must be accurate and up-to-date. This booklet should be revised annually and provided to residents. Better support is needed to help residents remain more physically and mentally active. Increased staffing is needed to meet the very high dependency needs of most residents. Training provision must be relevant to the needs of residents admitted and to meet the claims of the home that it professionally addresses the specialist support needs of residents. Timescale for action 15/08/07 2 3 OP12OP12 OP14OP14 OP27OP27 OP28OP28 OP30OP30 16(2 M&N) 13 (4,5). 18 (1) 15/08/07 15/08/07 Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 26 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 Chippendayle Lodge DS0000067120.V340256.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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