Inspection on 29/07/05 for Chipstead Lodge

This inspection was carried out on 29th July 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 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

Chipstead Lodge 03/04/08

Chipstead Lodge 04/04/07

Chipstead Lodge 17/10/05

Chipstead Lodge 25/11/04

Chipstead Lodge 23/06/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

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

CARE HOMES FOR OLDER PEOPLE Chipstead Lodge Hazelwood Lane Chipstead Surrey CR5 3QW Lead Inspector Mrs Susan McBriarty Unannounced 29 July 2005 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 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. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chipstead Lodge Address Hazelwood Lane Chipstead Surrey CR5 3QW 01737 553552 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Unlimited Ms Christine Margaret Dewan Care Home 36 Category(ies) of DE - Dementia (10) registration, with number of places DE(E) - Dementia - over 65 (14) LD(E) - Learning Disability - over 65 (2) MD - Mental Dissorder (10) MD(E) - Mental Dissorder - over 65 (14) Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 3. The age/age range of the persons to be accommodated will be: OVER 65 YEARS, 10 OF WHOM MAY BE IN THE AGE RANGE 50 TO 65 YEARS 4. Up to 10 of the younger adults accommodated may have a mental dissorder (MD) or dementia (DE) 5. Up to 14 (fourteen) of the older people accommodated may have a mental dissorder MD(E) or dementia DE(E) 6. Up to 2 (two) of the older people accommodated may have a learning disability LD(E). 7. Mental Disorder or Dementia over 50 years of age (5) 8. Mental Disorder and Learning Disability over 65 years of age (5) Date of last inspection 24th November 2004 Brief Description of the Service: Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first for 2005-2006. The Inspector arrived at 8.30am and the inspection ended at 12.50pm. During the inspection five (5) residents and three (3) staff were spoken to by the Inspector excluding the owner of the home. The manager was not present and the owner assisted the inspection process. A tour of the home took place and included all the communal areas, the Inspector had seen the new bedrooms previously as part of the registration process. The remaining bedrooms were locked by the residents and were not seen during this inspection. A number of documents were sampled these included; care plans, staff personnel files and staff training information. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements have been made from the inspection these include; the need to fully review the recruitment procedure in order to ensure that the home meet the requirements of The Care Homes Regulations 2001. This Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 6 requirement is supported by other requirements to review application forms and reference checks. During the inspection it was found that communal towels were in use in a number of the bathrooms including those where paper towels had been provided. The use of communal towels must cease and staff must have access to paper towels in all bathrooms throughout the home. These actions will reduce the risk of cross infection. The requirements made are noted at the end of this report. 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. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 standard(s) 3 Prospective residents to the home are assessed before a placement is offered. Standard six (6) does not apply to this home. EVIDENCE: The standard of the assessments evidenced during the inspection were varied. It was found that those residents who had been at the home some while had unsigned; undated assessments that lacked detailed information. The most recent admissions evidenced that the pre-admission process had improved. The documents are more detailed and have been signed and dated by the assessor. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 10, The home provides care plans and risk assessments for residents however, they require further work to ensure a consistent approach to meeting the needs of the residents. The health care needs of the residents were documented and the home was responding to the needs of the residents. EVIDENCE: The care plans require further work to ensure clarity. Review dates are evidenced within the care however there is no evidence that the residents have been involved in the review. A requirement is made to review the care plan and where appropriate, involve the resident and enable them to sign and date their agreement to the care plan. A number of the risk assessments completed by the home had not been reviewed for some time. A requirement has been made to ensure that all the risk assessments are up to date and where appropriate involve the residents and enable them to sign and date their agreement. The files sampled evidenced the health needs of the residents and how those documented needs were being met. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 10 Those residents spoken to felt the home was meeting their needs, comments varied from ‘its all right, no problems’ to ‘I like it here’. The needs of the residents are such that a number of them would not be able to inform the CSCI of their views and wishes. Observations made during the inspection noted that staff responded to the residents need in a respectful manner. The residents may use their own bedrooms to meet visitors or use one of the communal areas for example the conservatory or one of the two lounges. All the bedrooms are single use. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 standard(s) 13, 15 Family and friends are able to visit the home throughout the day. The meals are appealing and varied. EVIDENCE: Those residents who have maintained contact with friends and family and are able to see them at any time during the day. In discussion with the new cook it was confirmed that some visitors choose to join the residents they are visiting for a meal. This was evidenced on the day of the inspection. The Inspector observed that residents were able to ask for a drink at any time and when a specified resident did not want the lunch on offer they were asked what they would prefer and this was prepared for them. Fresh vegetables were seen as available for use by the home. The home has three dining areas, two of which are part of the new build. The kitchen area requires refurbishment and this is noted in the Environment section of this report. The meals times are at set period during the day however the residents can choose to eat at any point during that set period. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed during this inspection. EVIDENCE: Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 25, 26 A tour of the home’s communal areas took place and further work is required to ensure that the risk of cross infection is reduced. EVIDENCE: The home has recently undergone significant building work and has increased the number of bedrooms available. One resident spoke to the Inspector about the new build and stated that while they preferred the new bedrooms they did not wish to move to one. Further work is planned by the proprietor to complete the building work. This includes improvement to the front of the home. The area to the front of the home is mainly used for car parking and is covered in soil, to the rear of the area are trees and weeds. The improvements are expected by the proprietor to be completed within the next two months. Access to the sides of the home are gated to reduce the risk of falls and other incidents involving residents, once the area to the front of the home is completed the risk should reduce further. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 14 The grounds to the rear and side of the home have recently been landscaped, some minor work remains outstanding and these areas have been cordoned off for safety reasons. A patio area is provided to the rear and one side of the home and additional seating provided for the residents use. Ramp access is available for residents to access the large lawn area and a recent barbeque held at the home was successful. The kitchen is due for a full refurbishment including extending the working and storage areas. This work is much needed and was required by the environmental health office. The proprietor had previously advised the CSCI that work would be completed by the end of July 2005. However the current plan is for work to commence by the end of August 2005. A risk assessment is in place to ensure that food carried from the kitchen to the new dining areas can be done so safely. The Inspector saw evidence of the building quotes for the work on the day of the inspection. Assisted bathing facilities have been provided as part of the new build and are adequate for the resident’s current needs. All the bedrooms are single use; the new build bedrooms have en-suite facilities. None of the bedrooms in use were seen during the inspection. The home has two lounges, three dining areas, a conservatory and large grounds all of which are accessible to residents and their visitors. The heating and lighting and laundry area provided is adequate and meet the Standards. Further work is required to reduce the risk of cross infection. The bathrooms and toilets evidenced the use of communal towels; in at least one bathroom the towel was dirty. In the new build paper towels and liquid soap are available, this is not the case in older parts of the home. A requirement is made to ensure that paper towels and liquid soap are available for use by the staff in all communal bathrooms and toilets in order to reduce the risk of cross infection. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29, Further work is required to ensure that the home meets the recruitment requirements of The Care Homes Regulations 2001. EVIDENCE: Standard 30 was not fully assessed however evidence was seen of staff training courses being attended including risk assessment and risk management, induction and medication. The home has recruited a new personal assistant to the manager and this person will be responsible for re-organising the information held at the office including staff and resident files. A new cook has also been engaged and the service users spoken to wanted to ensure that the Inspector was aware of this, one specified resident noted their relief at the new cook’s arrival. However work is required to ensure that the home meets the requirements of The Care Homes Regulations 2001. The Inspector spoke to the organisations Business Manager who undertakes all the organisations recruitment processes in order to clarify the requirements. Requirements were made for the home to ensure that the application forms included the need for a full employment history. That references be sought from the prospective staff member’s last two employers, at the time of the inspection those files sampled included character references. In addition the Inspector was unable to sample the Criminal Record Bureau (CRB) checks as some had been destroyed as the Business Manager had been advised to do so Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 16 by the CRB Inspectors. This matter has now been resolved. The records kept at the home did not indicate which records had been destroyed; other notes were handwritten across the bottom of the form and may lead to confusion. The original documents must be kept at the home and a full clear record kept of the details of the CRB check. The CSCI will then be able to sample the CRB records to ensure they meet the stated Regulations. The home employs a number of overseas staff and one of the files sampled noted that a specified persons visa was out of date. The proprietor agreed to check the details as a matter of urgency. Given the findings of the inspection a further requirement was made for the organisation to review the recruitment and selection policy and procedure to ensure that it meets The Care Homes Regulations 2001 in full. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 These standards were not fully assessed, however the findings of the inspection reflect on these standards and are therefore noted further in this section of the report. EVIDENCE: The manager was not present during the inspection. The homes record keeping including care plans, risk assessments and recruitment require further work to meet the standards. The records are held securely and access for inspection purposes is available in the absence of the manager. The practice of providing communal towels increases the risk of cross infection to the residents and as noted previously a requirement has been made to provide paper towels and liquid soap to all communal bathing and toilet areas. Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 x 3 2 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x 2 2 Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 19 No 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 7,37 Timescale for action 15(1)(2) The registered person must 31st August (c) review the care plans and, where 2005 appropriate, enable the service users to sign and date the agreed care plan. 13(4)(b) The registered person must 31st August (c) ensure that the risk assessments 2005 are reviewed, updated and where appropriate, enable the service users to sign and date the agreed outcome. 13(3) The registered person must 9th ensure that paper towels and September liquid soap are provided in each 2005 of the communal bathrooms. 19(1)(a)( The registered person must 31st August b)(c)(3)(4 ensure that all persons working 2005 )(a)(b)(c) at the home have a current CRB Schedule check and that the original 2, documents are kept at the home 19(9)(10) and an accurate record kept of (11) the CRB check, the documents to be open for inspection. 19(1)Sche The registered person must 31st August dule 2 (6) ensure that the application forms 2005 for prospective staff are updated to include the requirement for a full employment history. 19(1)(4) The registered person must 31st August (c)Schedu review the use of character 2005 le 2 references. H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 20 Regulation Requirement 2. 7,37 3. 26,38 4. 29 5. 29 6. 29 Chipstead Lodge 7. 29 18(1)(a)( b)(c )(2), 19(1)(2)( 3)(4)Sche dule 2, 19(9)(10) (11) The registered person must ensure that a full review takes place of the homes recruitment procedure and of the procedure enabling any person to work at the home if not employed by the organisation in order to ensure that The Care Homes Regulations are met in full. 9th September 2005 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 Good Practice Recommendations Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Chipstead Lodge H58-H09 S13602 Chipstead Lodge V243210 290705 Stage 4.doc Version 1.40 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!