Inspection on 03/04/08 for Chipstead Lodge

This inspection was carried out on 3rd April 2008.

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

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

Other inspections for this house

Chipstead Lodge 04/04/07

Chipstead Lodge 17/10/05

Chipstead Lodge 29/07/05

Chipstead Lodge 25/11/04

Chipstead Lodge 23/06/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Chipstead Lodge Chipstead Lodge Hazelwood Lane Chipstead Surrey CR5 3QW Lead Inspector Debbie Sullivan Key Unannounced Inspection 3rd April 2008 09:10 X10029.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 Chipstead Lodge DS0000013602.V361041.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 and Care Homes for Adults 18 – 65*. 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 DS0000013602.V361041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chipstead Lodge Address Chipstead Lodge Hazelwood Lane Chipstead Surrey CR5 3QW 01737 553552 01737 559284 chipstead@careunlimited.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) Care Unlimited Ms Christine Margaret Dewan Care Home 36 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (14), Learning disability over 65 years of age of places (2), Mental disorder, excluding learning disability or dementia (10), Mental Disorder, excluding learning disability or dementia - over 65 years of age (14) Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. The age/age range of the persons to be accommodated will be: OVER 65 YEARS, 10 OF WHOM MAY BE WITHIN THE AGE RANGE 50 TO 65 YEARS Up to 10 of the younger adults accommodated may have a mental disorder (MD) or dementia (DE). Up to 14 (fourteen) of the older people accommodated may have a mental disorder MD(E) or dementia DE(E). Up to 2 (two) of the older people accommodated may have a learning disability LD(E). Mental Disorder or Dementia over 50 years of age (5). Mental Disorder and Learning Disability over 65 years of age (5). Date of last inspection 4th April 2007 Brief Description of the Service: Chipstead Lodge is set in a rural area of Chipstead within walking distance of some local shops. The property is an older style building that has a ground floor extension to provide further accommodation. There are two floors to the main part of the property and the first floor can be reached by a shaft lift. A number of the rooms, including a few on the ground floor, require the service users who occupy them to have reasonable mobility as they need to access several steps up to them. There is plenty of car parking space at the front of the home. Communal areas include the dining room and three lounges one of which is a quiet lounge. There is a well kept garden and patio area. Service users are offered opportunities to participate in activities provided by the home. The home is one of three owned by the Care Unlimited and it caters for a range of service user needs. The current weekly fee for the service ranges from £300 to £700. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over seven hours; during the visit time was spent with service users, the registered provider, registered manager, the organisation’s quality assurance manager and care and catering staff members. A tour of the home took place led by a service user and service users were joined at lunchtime. Throughout the day service users and staff were helpful in providing information and assisting with the inspection. A range of documentation was read including some service users care plans, staff files, daily records, medication recording and policies and procedures. Information was also gained from survey forms sent in by relatives and health and social care professionals. The submission date for the home’s annual AQAA (Annual Quality Assurance Document) had not been reached when the inspection took place, so the information in it was not available prior to the inspection although the manager was working on it and submitted it soon after the visit. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: The needs of people thinking about moving into the home are fully assessed before they are offered a place, and they are given information about the service. Service users have a range of needs and they are viewed as individuals, staff are aware of their particular preferences and needs. There is effective communication with health and social care professionals and relatives, and any concerns are quickly reported. Health needs are well met and recorded. Service users are supported to be independent and maintain skills and are involved in the running of the home; there are residents’ meetings and quality assurance audits. Concerns and complaints are managed effectively. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 6 The environment is pleasant, homely and well maintained with a busy but family like atmosphere. Staff recruitment procedures are thorough and no agency staff have been used this provides consistancy of care. What has improved since the last inspection? What they could do better: Care plans continue to need to be streamlined so that more information is centralised and easily accessible. The home needs to explore ways in which more service users, especially those less mobile or independent can be offered activities in the home and the community. Service users need to be offered daily meal choices and the menu be clearly displayed. A record needs to be kept of the meals that each service user eats every day. The area of flaking paint in the upstairs shower room needs attention and water temperatures must be kept at a safe level whilst being warm enough in all areas of the home. Small tables to hold drinks should be provided in lounges and other areas where service users may spend time. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 7 The home must continue with it’s stated intent to work towards achieving over fifty percent of the care staff having NVQ in care at level two or above. Sponsoring authorities should be approached regarding transfer of the appointeeship of some service users from the service to themselves or to appropriate others. 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. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Information about the service is available to potential service users and their representatives, and they are welcome to visit the home before deciding to move in. Needs are assessed prior to admission and service users are only admitted if needs can be fully met. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a statement of purpose and service user’s guide, service users spoken with had been provided with information about the home before moving in or said relatives had made the arrangements for them. One service user said they had visited with their social worker, a relative stated on a survey form that they spent a long time seeking a suitable service and were satisfied with Chipstead Lodge. A service user spoken with who had moved from another service said “I like it here, it is better than my previous home”. The home accommodates service users with a range of needs, the manager said she assesses each potential service user following receipt of their assessment by a local authority, if a second opinion is needed a manager from another of the organisation’s homes help with the assessment. The assessment form has recently been updated to provide more information. The majority of service users are sponsored by local authorities locally and further afield and contracts are drawn up with the relevant agency, private service users have individual contracts. The home does not provide intermediate care although independence is encouraged and the manager gave an example of a service user who moved out to be more independent in 2007. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are well met and recorded and needs are reviewed regularly. Service users are treated respectfully and with dignity. Medication procedures are in place that protect service users and staff. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 12 EVIDENCE: Work has taken place to streamline care plans since the last inspection, then information about service users was held in a large number of different files making some of it difficult to access. Some information is now archived and care plans contain more working documents that can be used on a daily basis by staff. Some information such as weight monitoring is still kept in a separate file, the manager and provider said that the organisation is exploring computer databases and they hope to purchase one so that information can be more easily centralised. Care plans are reviewed monthly for all service users including those under sixty five, service users can access their plans if they wish. Care plans contained assessments, review information, recording of contact with health and social care professionals and daily recording detailed enough to give a good picture of any changes or concerns about the service user. Due to the needs of service users a range of outside professionals some of whom specialise in a particular service user group are accessed, such as Community Psychiatric Nurses. The GP visits once a week and service users who wish to can see him. The manager and staff recognise the individual nature of each service user’s needs, which sometimes can change on a daily basis, and routines must be flexible to accommodate this. One service user with a mental health diagnosis was encouraged to go out independently when feeling well and their wish to stay in bed a lot of the time when not feeling so well was respected. A survey form from a health professional included the comment that, “The care service addresses the social, emotional and psychological needs of the client to the highest standard, using person centred approach”. A relative of a service user stated on their form that the home kept in frequent contact when the service user was in hospital, and the service user recuperated better at the home than in hospital as the home was familiar with their specialist needs. Good health is promoted and the manager is trying to encourage service users who smoke to give up. If service users wish their preferences in the event of terminal illness and death are recorded. One service user had recently been diagnosed with a terminal illness; a Marie Curie Nurse visited them during the inspection and a relative was visiting as well. The home had taken prompt action to request the exploration of symptoms that led to the diagnosis. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 13 Service users who require help with their personal care are attended to in private; there are some double rooms that have curtaining to allow for privacy. One double room included a bed that was up against a wall not giving space for staff to have access on either side, the manager said that this would be risk assessed and the location of the bed was the service user’s preference. There is a discreet telephone area and quiet lounge for private discussions to take place. Medication is securely stored and staff administering it have medication training. Storage has improved, as there is now a temperature gauge in the medication room, although temperatures are checked they need to be recorded daily. Mar sheets seen had been properly completed. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 15 12,13,14 and 15 People who use this service experience adequate quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Service users are offered activities although not all have equal opportunities to access them. Contact with relatives and friends is supported. Meals are nutritious although service users need to have more clear information on the daily choices available. EVIDENCE: The home employs an activities coordinator who works five days a week including Saturdays. The amount of activities and outings on offer has improved and more trips to venues such as the theatre are offered, although take up can be variable. Regular activities available include exercise and reminiscence sessions, shopping trips, pool and music sessions. Special events such as Valentines’ day, religious festivals and birthdays are celebrated and an entertainer visits regularly. Seasonal activities are planned well in advance, such a summer barbeque. Some service users go out shopping on a regular basis with the activities coordinator, they tend to be the more able people or those needing some one to one support. Service users who may need more encouragement to take part in activities at home or in the community can miss out and there are times when the coordinator may be spending a long time with one person. The manager and provider were aware of this and the AQAA says that the home is considering ways in which more people can have opportunities to participate in activities. The home does try hard to establish each service user’s interests and offer a fairly varied programme although it needs to ensure that everyone has sufficient opportunities to be involved in activities they like. One service user was working part of the week in the kitchen, they said they enjoyed this, it was interesting and the part time arrangement suited them. Another service user regularly goes out independently, the manager gave an example of a service user who had recently been to the theatre on their own. Service users are encouraged to sort out their own laundry for washing. The Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 16 routines of the home are flexible and service users are able to get up and go to bed when they choose. Service users were joined at lunchtime, those spoken with said that they usually liked the meals. Lunch was freshly cooked and well received, there were fresh vegetables and there was a pleasant atmosphere in the dining room. Service users said that meals had improved lately, one had complained about repetitive puddings being served. Service users knew that if they did not like a meal they could have something else to eat and the cook was aware of religious or dietary needs and preferences, although the menu board located in the corridor near the dining room did not state that there was a daily choice of main meal on offer. It was not clear that service users were aware there should be a set choice and if they liked neither they could still choose something else. The manager said that new menus were being introduced following consultation with service users and they and the provider would look at reintroducing menus on tables and providing a large menu board in the dining room. Contact with relatives are supported, service users spoke of going out with relatives and of visits, comments on relatives’ survey forms were positive regarding communication from the home. One relative stated, “This home is accommodating always when I or other members of the family visit”. There is space available for visits to take place other than in bedrooms. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. Service users and others have access to a complaints procedure and their concerns are addressed. Service users are protected from harm by the policies and procedures in place and staff are aware of what constitutes adult abuse. EVIDENCE: The home has a complaints procedure; complaints referred directly to the manager that can be addressed quickly are record and responded to promptly, examples were about the quality of meals. The Quality Assurance manager responds to written complaints referred to the organisations’ head office, one had been referred to him since the last inspection and had been thoroughly addressed. The complaints procedure is on display in the home. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 18 The home has an adult protection procedure and all staff receive adult protection training. There had been no safeguarding alerts made since the last inspection. Information on whistle blowing processes is available for staff. Training is tracked and updates provided, care staff spoken with were aware of adult protection procedures. The legal rights of service users are respected and they were being offered the opportunity to vote in local elections during the visit as voting cards had arrived, although it was reported that take up was not enthusiastic. Due the nature of the service user group there is an alarm system on the front door that sounds when it is opened, it was fairly new when the last inspection took place and very noisy, this is now rectified and it is quieter. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 20 19,20,21,22,23,24,25 and 26 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, homely and well-decorated and comfortable environment. Some improvements to the environment are needed, to make sure that there are no risks to service users. EVIDENCE: The tour of most parts of the home was in the company of a service user who was very helpful and informative. The home was clean, well decorated and well furnished. Shared areas are the main and quiet lounges, a seating area near the entrance, the dining room that is split on either sides of a corridor and an activities/pool room leading onto a small conservatory. The main lounge had been attractively refurbished since the last inspection. The conservatory is the designated smoking room; it is recommended that the sign saying it is the smoking room is more in evidence as it was well above eye level. There were not enough coffee or occasional tables in all the seating areas and two service users were balancing hot drinks precariously on a chair arm or their lap, the provider undertook to address this urgently. There is a large garden with a safe patio area that service users said they use in good weather. During the visit service users were accessing various areas in the home that they wished to freely and spending time in their rooms or with others. There is a dedicated hairdressing room, the hairdresser visited during the inspection. There are bedrooms in the old part of the home and new annexe; those seen were all very personalised and included personal furniture, pictures, ornaments and other items. Most service users have keys to their rooms, it is recommended that where it is assessed there is risk involved to key holding and agreed with a local authority this be recorded. One service user has a pet budgie in their room, another service user helps look after it and another has tropical fish. Service users spoken with were happy with their rooms; one said they were on the ground floor due to mobility problems. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 21 Some rooms are ensuite, there are shower/bathrooms on both floors, the upstairs shower room had a small area of flaking paint on the wall and the water temperature was too hot, whereas the water tested in the annexe downstairs was lukewarm, there had been an ongoing problem with the boiler that the manager was aware of and was being addressed. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28,29 and 30 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. A well-trained and well supported staff group meets the needs of service users. The homes’ recruitment processes are thorough and help to ensure that service users are protected. EVIDENCE: The manager, deputy manager, care staff including senior carers, catering and housekeeping staff, an activities coordinator and the manager’s personal assistant staff the home. The home was adequately staffed on the day of the Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 23 inspection; one carer had gone out with a service user to a medical appointment. The home does not need to use agency staff and staff turnover is low, this provides consistency for service users. A comment from a service users on their survey form was “The staff are very nice people”, service users spoken with said they were satisfied with the support they were offered. Some survey forms referred to there sometimes being a shortage of staff, the rota did not reflect this although the manager acknowledged that at times when individual needs required more attention, sometimes unpredictably, then staff could be somewhat stretched. Staff receive regular recorded supervision and there are team meetings, a notice about the next meeting due the day after the inspection was on display. The quality assurance manager tracks staff training and updates of core training are given. Specialist training includes dementia training, sensory awareness and epilepsy. Staff are tested quarterly on their learning. New staff receive induction, one staff member spoken with said that they had shadowed experienced staff until they felt confident. Comments on staff survey forms included “Courses related to my role are offered and encouraged” and “My manager always asks me to read care plans when there are any changes with clients”. The home is working towards all care staff having an NVQ in care at level 2 or above. Staff files were sampled including files of new and well-established staff; files contained the necessary recruitment documentation, the head office manages CRB and POVA checks and CRB’s are updated for staff that have been employed for some time. During the visit staff were observed to treat service users respectfully and call bells were answered promptly. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 25 31,32,33,34,35,36,37 and 38 People who use this service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The home has an inclusive and homely atmosphere and is well managed. There needs to be increased vigilance to make sure that there are no health and safety risks. Service users have opportunities to comment on and be involved in the running of the service. The organisation undertakes internal quality assurance and acts on its findings. EVIDENCE: The registered manager is well established at the home and is suitably qualified. The home has a pleasant and friendly atmosphere and service users who sent in survey forms or who were spoken with during the visit were mainly satisfied with the service. An outside professional that sent in a form stated, “The staff are very friendly and you can build up a good rapport and relationship with them, the home is very clean and homely feeling”. Investment is being made in the service with an ongoing programme of refurbishment and training. Quality assurance is taken seriously, the organisation’s quality assurance manager undertakes Regulation 26 visits, monitors the homes’ quality within the organisation overall and audits service user and other stakeholder internal survey forms. The 2007 survey of service users showed a good level of satisfaction with service users showing some dissatisfaction about meals; this had been addressed with more service user consultation. The home has gained the Investors in People Award. Organisational policies and procedures are in place and are available to staff. The majority of service users have appointees; the home remains appointee for ten service users who have lived there for a long time. A requirement was made at the last inspection that the interest from the treasury account that their savings is in is apportioned to them, this has been met. The home now does not admit people who have no independent appointee. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 26 The provider is aware that the home should not manage the monies of the long standing service users and is trying to address this with the sponsoring authorities. Records seen were up to date and stored securely, safe working practices were observed during the visit and equipment is serviced. The over hot water in the upstairs shower room and flaking paint there pose risks for service users and measures must be taken to ensure that action is taken to reduce them. Fire precautions are good and fire equipment is regularly serviced, fire practices involving evacuations take place a service user confirmed that they had been involved in them. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 3 5 3 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 2 22 X 23 3 24 3 25 2 26 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 37 3 38 2 Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 YA17 Regulation 12(2)(i) Requirement “The registered person shall provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such a time as may be reasonably required of service users” In that the daily menu must be clearly displayed for all service users and include a choice of meal. 2. OP38 YA42 13(4)(a) “The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety” In that water temperature must be monitored throughout the building to ensure that it does not exceed 44 degrees and pose a risk to service users. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 29 Timescale for action 30/05/08 30/05/08 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 OP9 YA20 OP12 YA11 YA14 Good Practice Recommendations It is strongly recommended that the medication room temperature be recorded daily. It is strongly recommended that all service users have equal opportunities to participate in activities, including those necessary on a one to one basis and the appointment of more activities staff be considered. It is recommended that service users’ daily meal choices be recorded. It is strongly recommended that sufficient coffee and occasional table be made available in all lounges and seating areas for service users to place drinks on. It is recommended that the smoking room sign be more visible and at eye level. 5. OP21 YA27 It is strongly recommended that the unsafe and unusable bath seat in the downstairs bathroom be replaced urgently. It is recommended that where it is assessed as unsafe for a service user to hold a key to their bedroom this is recorded. It is recommended that the upstairs shower room be redecorated and as suggested by the provider tiled to avoid flaking paint and risk of cross infection. It is strongly recommended that the home continue in it’s discussions with sponsoring authorities about relinquishing appointeeship for some service users as it is not appropriate that it manages any service users monies. If this is not progressed a requirement may be necessary in the future. DS0000013602.V361041.R01.S.doc Version 5.2 Page 30 2. 3. 4. OP15 YA17 OP20 YA28 6. OP24 YA26 7. OP26 YA30 8. OP35 YA23 Chipstead Lodge Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Maidstone 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. Extracts may not be used or reproduced without the express permission of CSCI. Chipstead Lodge DS0000013602.V361041.R01.S.doc Version 5.2 Page 32 - 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. 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