Inspection on 04/04/07 for Chipstead Lodge

This inspection was carried out on 4th April 2007.

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 17/10/05

Chipstead Lodge 29/07/05

Chipstead Lodge 25/11/04

Chipstead Lodge 23/06/04

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Insight - Eastchurch

Southfields

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Dovedale Court

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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 Damian Griffiths Unannounced Inspection 4th April 2007 10:00 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.V333080.R02.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.V333080.R02.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 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.V333080.R02.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 (twp) 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 17th October 2005 Brief Description of the Service: Chipstead Lodge is set in a rural area of Chipstead within walking distance of a few 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 is reached by a lift. A number of the rooms, including a few on the ground floor, require service users to have reasonable mobility to reach them as they need to access several steps to reach them. The home is one of three owned by the company and caters for a range of service user needs. The area to the front of the home provides ample car parking. At the time of the inspection the ratio of over 65’s to under 65’s was 20 – 15. Costs dependent on care needs start at £400.00 per week. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took 7 hours commencing at 10:30am and ending at 5:30pm. Mr Damian Griffiths regulation inspector completed the visit. The Registered Manager, Ms Christine Margaret Dewan, was present and represented the establishment. The inspector ensured that time was spent observing talking and noting interaction between staff and service users. Some service users relied on relatives and staff to meet their care needs and to speak on their behalf. A tour of the premises was conducted and the inspector stayed for lunch. Samples of service users care need assessments, care plans and the views of service users met during the visit contributed to this inspection report and fourteen CSCI surveys were received from service users, one from a relative, five from social care practitioners linked to the home and two from healthcare practitioners. The results and comments have also been included. Staff files were inspected for evidence of good practice in the following areas; recruitment, training and the distribution of staff skills as reflected in the staff rota for the day. To assist ease of reading the inspector does not refer to older or younger residents but addresses all as service users. The inspector would like to extend thanks to the service users their relatives, management and staff at Chipstead Lodge for their time and hospitality. What the service does well: The inspector was shown around the home by the service users. The home was clean light and airy consisting of communal areas for dining, leisure and relaxation and areas surrounding the kitchen area. The home had recently been tastefully decorated. The home provided the residents with useful information prior to their stay at the home and received a full care assessment from the home and social and healthcare practitioners involved in their care. One social care practitioners said that ‘always feel that staff and manager demonstrate an excellent understanding of people with dementia type problems’. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 6 The home offered service users a variety of activities that supported and encouraged friends and families to visit and encouraged self-improvement. The one relative completing the CSCI survey said: they were welcomed into the home at any time and they could visit their relative in private. They were kept informed of important care matters and that there were sufficient staff always on duty. They were aware of the complaint procedures although they had never made a complaint and that they were aware of forthcoming inspections and had access to inspection reports. Overall, satisfied with the care provided. Care plans inspected had received a review in the last six months and a record of health and social care practitioner involvement was evident in the service users files. Service users were encouraged to pursue new interests and a successful recycling scheme had been introduced by one of the service users at the home. Staff received training that matched the needs of the service users. What has improved since the last inspection? What they could do better: The home must be seen to address and operate an effective and inclusive complaints system for service users and investigate their complaints and concerns to the best their ability. The registered person must ensure that the application forms for prospective staff are updated to include the requirement for a full employment history and that the home must review it’s use of character references in line with The Care Homes Regulations 2001 (as amended). Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 7 The home must be seen to represent the best interests of the service user by providing regular, minuted house meetings whereby service users are supported to discuss their concerns, plan, activities and participate in the running of the home as appropriate. The home must ensure that any monies being held on behalf of service users is guided by clear policy and practice and any monies accrued are transferred into the service users own bank/building society account were it will accrue a reasonable monthly/annual interest and be in their best interest. Several good practice recommendations were made; That the home should work towards care plans and essential care need information being accessible in an easy to read and accessible care plan folder/book and that the home computerises the care plan system to combine care plans, risk assessments, daily notes, planned activities and any other relevant information and that the service user has access to it. That the records for ‘medicines being returned’ should also carry the pharmacy stamp and that the home acquired a temperature gauge to ensure that medication was being stored at the correct temperature. The home aim towards service users being supported to devise menus that containing the ‘five a day’ fresh fruit and vegetables required providing a healthy and nutritious diet. It was recommended that the home ensure that service user choices and diversity are explored in the next quality assurance audit. That a less noisome security alarm system be investigated and that it relates more to care needs of the service users. That an addendum be made in the ‘staff handbook’ containing contact details currently to be found on the office notice board regarding whistle blowing ‘help-lines’. That the home considers blinds/heat reducing window coatings and environmentally friendly solutions to the problem of reducing summer heat. 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.V333080.R02.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.V333080.R02.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): Standard 1 and all key standards were inspected. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The home provided the residents with useful information prior to their stay at the home. Service users received a full assessment of their care needs from the home and their social and healthcare practitioners. EVIDENCE: Service users completing the CSCI survey all stated that they had received enough information about the home. The homes Statement of Purpose had been updated and service users consulted confirmed that they had received a Service Users Guide’, however, none could recollect when they last had reason to look at it. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 10 The documentation had been reviewed and updated but this will need to continue to keep pace with changes such as the new address for CSCI this was noted by the manager her administrator. It is recommended that the home/s consult the CSCI Website on a regular basis and update accordingly. A sample of 5 assessments were inspected and ranged from new and existing service users. All care need assessments were in place and the service users local authority social care team as well as the home had completed them. The assessments were contained in a separate folder from the care plans and stored in the office. One relative completing the CSCI survey said: they were welcome into the home at any time, they could visit in private and were kept informed of important matters. Please see the ‘good practice’ recommendation section of this report. Chipstead Lodge DS0000013602.V333080.R02.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): All key standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service user had care plans that reflected their daily care needs, risks and health care needs, however, there was room for improvement. EVIDENCE: The five care plans sampled were in place but not all had been signed. Service users and relatives had participated in the planning and reviewing of their care plans. The service users informed the inspector that they found care plan Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 12 reviews tolerable but did not always sign the agreed care plans. Care plans inspected had received a review in the last six months. Assessments, care plans, risk assessments, daily notes, activities were available but not in one place but in separate files. The inspector and manager spent a lot of time sorting out the various separate care plans for five residents that amounted to almost 25 different folders due to the way in which they had been organised and it was difficult to clarify the information contained. Any new staff member would find similar problems and would not be able to respond to a problem unless a more experienced member of staff was on duty to assist. A recommendation was made that the home should work towards care plans and essential care need information being accessible in an easy to read and accessible care plan folder/book and that the home computerises the care plan system to combine care plans, risk assessments, daily notes, planned activities and any other relevant information and that the service user has access to it. Most service users completing the CSCI survey confirmed that staff listened and acted on what they said. Evidence of this could be found in the records provided by the home. Details included how service users made choices: one of the sample groups was a woman with dementia who would smile when indicating her choice. The CSCI survey also indicated that staff were there when they were needed and agreed that they received the care they needed, one service user commented he was; generally happy, behaviour of some can be irritating. Records of health and social care practitioner involvement were evident in the service users files. Regular reviews had been arranged and included the ‘Care Plan Approach’ (CPA) records that involved psychiatrists and regular visits from the Community Psychiatric Nurse. Chiropody was available free to service users with a medical condition such as diabetes but all other residents were required to pay. Five completed CSCI surveys were received from social care practitioners and one stated that at a recent review was pleased with how Mental Health needs were being met. Medication administration records, a tablet count, liquid medication check, daily distribution methods, storage and disposal of medicines were inspected. Service users photographs appeared upon the front of their medication charts and they contained a complete daily record of medicines distributed. The two CSCI surveys received from health care practitioners had no issues relating to the administration of medication at the home. It was recommended that the records for ‘medicines being returned’ should also carry the pharmacy stamp and that the home acquired a temperature gauge to ensure that medication was being stored at the correct temperature. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 13 A relative completing the CSCI survey said: they were welcome into the home at any time, they could visit in private, was kept informed of important matters, was consulted about care and was satisfied the care overall. Please see the recommendations section of this report. Chipstead Lodge DS0000013602.V333080.R02.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): All key standards were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offered service users a variety of activities, supported, encouraged friends and families to visit and supported self-improvement however it was not clear how service users diverse needs and their involvement in the planning and provision of nutritious meals was being met. EVIDENCE: Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 15 Church of England and Roman Catholic Church services were available and the manager confirmed that any other religious denominations would be honoured if required, however, it was not clear how the home was meeting the diverse and cultural needs of the service users. One service user employed at the home had managed to quit smoking and another was able to complete ‘needle-point’ sewing project, both agreed that this helped to improve their lives at the home. Each service user had received an assessment of activities that they enjoyed pursuing and the home. Most of the service users enjoyed reading watching TV and some like to smoke and another was planning to grow a vegetable garden. Activities had been planning through out the year and on a daily basis such as: shopping, keep fit table games, monthly activities involved Valentines Day Chinese New Year and Pancake day and a party twice monthly, such as a Easter party and a summer BBQ. Service users were offered holidays and days out although some service users consulted found it difficult to venture out and sometimes changed their minds about going at the last minute. Regular days out were far more attractive and some service users would like this to increase. Out of the fourteen CSCI surveys received nine service users usually liked the food other comments regarding the food included; ‘I can ask for something else’, ‘The quality of the food is not always good’ (quality of purchase not outcome), ‘different if the chef is not there’. The inspector joined the service users for lunch. The meal presented to the service users differed from the set menu due to organisational problem and the chef was absent and all meals were served with chips. Service users stated that the menus were selected by the home and contained a limited choice of fresh vegetables. A recommendation was made that the home aim towards service users being supported to devise menus that containing the ‘five a day’ fresh fruit and vegetables required providing a healthy and nutritious diet. Please see the requirements section of this report. . Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 16 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): All key standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users consulted did not feel that their complaints were being addressed. The home’s approach to security did not reflect the aims of the home although its commitment to safeguard the service users was of paramount importance. EVIDENCE: The homes had updated their complaints policy to include contact details for CSCI however this needed to be updated again. Seven service users completing the CSCI survey stated that they usually knew who to talk to if they were not happy and always knew whom to make a complaint to. No complaints were recorded in the homes records however service users had complained to the inspector. Complaint had been reported about the quality of food as mentioned in the previous section and also about the internal telephone system in place that was disturbing service users throughout the night because all the handsets rang whenever it was used. This was reported directly to the owner and manager who were visiting the home. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 17 A relative completing the CSCI survey said: they were aware of the complaint procedure, had never made a complaint, was aware of forthcoming inspections, had access to inspection reports and was satisfied with the care overall. The security system in place was had been updated since a service user had left the premises last year resulting in a police helicopter search. The home had an efficient alarm system in place and doors throughout the home were self-closing. However, the alarms were going off throughout the inspection merely by the opening of the front door. Service users confirmed that this was oppressive. It is recommended that a less noisome alarm system be investigated and that it relates more to care needs of the service users. The home followed the guidelines of the Surrey Multi-Agency Procedures for the protection of Vulnerable Adults and had an updated procedure available in the office and one case of alleged financial abuse was currently under investigation. The home had recently given staff a new staff handbook that contained the whistle blowing guidelines however this did not contain contact numbers of outside agencies although these could be found on a poster advertising the policy sited on the office notice board. It is recommended that an addendum be made in the ‘staff handbook’ containing contact details currently found on the office notice board regarding whistle blowing ‘help-lines’. Please see the requirements and recommendations section of this report to see how the home is to improve in this area. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 18 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): Standards 19, 20, 21, 23 24, 25 and 26 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefited from a clean and well-maintained environment that was secured by an efficient alarm system. EVIDENCE: A service user assisted the inspector to tour the premises. The home was clean light and airy consisting of communal areas for dining, leisure and relaxation and areas surrounding the kitchen area. The home had been Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 19 recently been tastefully decorated and there was commitment to ensure that regular maintainence was completed. The hot water temperature of a tap in the ground floor bathroom was above the safe limit of 44.C. and required alteration. This was tackled immediately by the home and the inspector noted the tap was adjusted to the correct temperature before leaving. The home provided a relatively comfortable environment despite the noise of the door alarms spoiling the potential for a homely atmosphere, as mentioned in the previous section of this report. The garden was well kept and accessible to a few services users who had access to their own personal room key. Bedrooms on the ground floor opened out to the back garden. Staff were required to assist service users with greater care needs into the garden area. The dining areas contained glass skylights that provided a light and airy atmosphere however service users consulted confirmed that during the summer months the dining area was ‘roasting hot’. The home confirmed that this was the case and had provided ‘air-conditioning units’ to address the problem. It was recommended however that the home also consider blinds/heat reducing window coatings and consideration to environmentally friendly solutions to this problem. Service users bedrooms contained en-suit bathrooms and reflected their individual requirements and personality. Nine service users commenting in the CSCI survey agreed that the home was always fresh and clean. Other comments included: ‘on the whole quite good’. The laundry area was clean, tidy and contained appropriate laundering facilitates required to run a modern residential establishment. Service users were pleased with the quality of the laundry they received. Please see the ‘good practice’ recommendations section of this report. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 20 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): All key standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff skill mix met the care needs of service users due to the quality of training available at the home however staff had not attained the national minimum standard for NVQ qualifications and the homes recruitment practice required improvement. EVIDENCE: Five completed CSCI surveys were received from social care practitioners, one stated that at a recent review she was pleased with how mental health needs were being met. None practitioners had made a complaint and one stated; ‘always feel that staff and manager demonstrate an excellent understanding of people with dementia type problems’. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 21 The Inspector spoke with members of the staff team, the manager and quality control manager regarding staff training. A comment received from a service user completing a CSCI survey had said; ‘staff here does a very good job’ The staff spoke of having regular training therefore samples of four staff files were inspected to see whether ‘skill mix’ and ‘training’ reflected the care needs of the service users. Staff featured on the night rota were amongst those selected and staff personnel records showed evidence of the staff the training received and this included; National Service Framework for Mental Health, medication, protection of vulnerable adults, loss of independence in care setting, leisure and social activities, challenging behaviour, safe moving and handling, fire safety, dementia, awareness, diabetes training and Induction detailing safety and procedures in and around the home. The skill mix of the staff available therefore met service users care needs. The pre-inspection questionnaire completed by the home manager showed that out of fourteen staff only 21 had attained level two of the National Vocational qualification, therefore, failing the target set for attainment by 2005 in accordance with the National Minimum Standards under section 23 of the Care Standards Act 2000. The home was required to show that robust recruitment procedures were in place by detailing the person’s previous employment status, providing complete criminal record checks for all staff, proof of identity, ensuring that two references and full employment histories were available in the staff file for inspection. The four staff files sampled showed that only one staff member had two references and none of the staff had a complete employment history. Criminal record checks and proof of identity however were all in place. Most service user’s completing the CSCI survey confirmed that staff are there when needed. A relative completing the CSCI survey said: they were satisfied with the overall care provided. Please see the requirements and recommendations section of this report to see how the home is to improve in this area. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 22 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): All key standards were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management structure needed to show how the home was being run in the best interests of the service users. The quality audits completed did not show how it had improved service users standard of care however there were no health and safety concerns at the home. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 23 EVIDENCE: The manager had attained a registered nursing qualification and was continuing to study for her Registered Managers Award. An example of the overall management structure of the home can best be seen in the ‘Health and Personal Care’ section of this report and the way the home had organised care plans into five different folders detailing aspects of care need making it difficult for the inspector and, therefore, new care staff to find out specific care information. Similarly, there was a need to consolidate the management structure, as it was not clear how information was used to promote changes that reflected the views of the service users and their care needs. This can be seen throughout the report in areas such as; care planning, menu provision, quality and choice of food, service user complaints, diversity and representation, recruitment, protection and the failure to recognise that the security alarm being used clashed with the National Minimums Standards to provide a homely environment. The home managed service users ‘pocket money’ in a ‘treasury account’. Clear details of service users balances were available for inspection and showed that some service users had acquired substantial amounts of ‘pocketmoney’ in their accounts over time. There was no indication of any paid ‘interest’ accruing in these accounts or how this system was serving the best interests of the service user. The quality control manager made monthly inspections to the three homes and completed a brief report that was sent to CSCI. The home had completed a quality audit regarding service users and relatives’ views but had not published these. A new Annual Quality Assurance Assessment (AQAA), is to be completed by the home and will be implemented by CSCI in due course. Service users that could talk to the Inspector during the inspection confirmed that they did have house-meetings but they did not feel they were taken seriously enough. It was not clear how often service users met with the managers and staff to discuss home related issues as there was a lack of minuted records of the meetings in evidence. The service users stated that they would like to see senior manager attending a house meeting at least twice a year. The CSCI survey results found that fourteen service users had stated that staff always listened, and acted on what they said. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 24 There were no health and safety concerns observed during the tour of the premises other that the hot water temperature of the bathroom tap that was recalibrated during the inspection. Please see the requirements and recommendations section of this report to see how the home is to improve in the areas identified. Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 25 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 X 3 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 3 21 3 22 X 23 3 24 3 25 3 26 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 2 34 X 35 2 36 X 37 X 38 3 Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 26 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 OP16 YA22 Regulation 22(1) 22(3) (4) Requirement Timescale for action 17/05/07 2. OP29 19(1) Sch2(6) 3. OP35 13(5),20 Schedule 4 Para 3 & 9. 4. YA39 OP33 24 The home must be seen to address and operate an effective and inclusive complaints system for service users and investigate their complaints and concerns to the best of their ability. The registered person must 17/05/07 ensure that the application forms for prospective staff are updated to include the requirement for a full employment history and that the home must review it’s use of character references. The home must ensure that 17/05/07 any monies being held on behalf of service users is guided by clear policy and practice and any monies accrued are transferred into the service users own bank/building society account were it will accrue a reasonable monthly/annual interest and be in their best interest. The home must be seen to 17/05/07 represent the best interests of the service user by providing regular house meetings DS0000013602.V333080.R02.S.doc Version 5.2 Chipstead Lodge Page 27 whereby service users are supported to discuss their concerns, plan activities and participate in the running of the home as appropriate. 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 YA6 OP7 Good Practice Recommendations A recommendation was made that the home should work towards care plans and essential care need information being accessible in an easy to read and accessible care plan folder/book and that the home computerises the care plan system to combine care plans, risk assessments, daily notes, planned activities and any other relevant information and that the service user has access to it It was recommended that the records for ‘medicines being returned’ should also carry the pharmacy stamp and that the home acquired a temperature gauge to ensure that medication was being stored at the correct temperature. It was recommended that the home ensure that service user choices and diversity are explored in the next quality assurance audit. The home aim towards service users being supported to devise menus that containing the ‘five a day’ fresh fruit and vegetables required providing a healthy and nutritious diet. It is recommended that a less noisome security alarm system be investigated and that it relates more to care needs of the service users. It is recommended that an addendum be made in the ‘staff handbook’ containing contact details currently found on the office notice board regarding whistle blowing ‘helplines’. It was recommended that the home consider blinds/heat reducing window coatings and environmentally friendly solutions to the problem of reducing summer heat. 2. YA20 OP9 3. 4. OP14 OP15 YA17 5. 6. YA22 OP16 YA23 OP18 7. OP19 YA24 Chipstead Lodge DS0000013602.V333080.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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.V333080.R02.S.doc Version 5.2 Page 29 - 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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