Inspection on 12/07/05 for Cholwell House

This inspection was carried out on 12th 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

Cholwell House 22/01/08

Cholwell House 16/01/07

Cholwell House 21/01/05

Cholwell House 09/01/05

Cholwell House 13/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Cholwell House Temple Cloud Bath & N E Somerset BS39 5DJ Lead Inspector Andrew Pollard Unannounced 12 July 2005 09:45 th 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. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cholwell House Address Temple Cloud Bath & N E Somerset BS39 5DJ 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) 01761 452885 Cholwell House Nursing Home Ltd To be appointed Care home with nursing 51 Category(ies) of DE Dementia registration, with number DE(E) Dementia - over 65 of places OP Old age (51) Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate 51 persons aged 50 years and over. Manager must be a RN on parts 1 or 12 of the NMC register. Staffing Notice dated 20/04/1998 and NCSC letters re: revised staffing levels dated 27/08/02, 03/03/03 and CSCI letter 08/04/05 apply Date of last inspection 21/01/05 Brief Description of the Service: Cholwell House is registered for 51 residents requiring personal or nursing care.The home is situated in a rural position and can be accessed by car or bus. The home is in part a converted older property with recently built extensions that provides single and double rooms on three floors and a choice of communal areas including a large conservatory. There is an internal link corridor to the new extension of 11 rooms with en-suite facilities and its own pleasant communal space. There is lift access to all parts of the home. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used in the production of this report; observation, discussion with residents and staff, tour of the home and sampling policies, records, care plans, meals. On the day of inspection the home had occupancy of 46. There were 6 requirements and 4 recommendations made during the previous inspection. Compliance has been achieved or is in hand for all those matters. General feedback was given to the manager on the day of inspection. All residents and staff are on first name terms. Staff and resident interactions were seen to be friendly and caring upholding the dignity of the residents. What the service does well: What has improved since the last inspection? An improved and clearly written contract/terms and conditions has been produced. Care staff have copies of the GSCC code of practice and related training taken place. Fire risk assessment has been carried out. The electrical installation safety inspection has been carried out. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 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 Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 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) 1,2,3 Prospective residents or their families have all relevant information to make a decision about the nature of the home. A thorough assessment of prospective residents needs is carried out. EVIDENCE: A revised clearly written Statement of Terms and Conditions is available to each resident as part of an information pack including statement of purpose and service user guide. These document are informative and clearly presented. The majority of residents are admitted through Social services or via the PCT who provide detailed assessment and enhanced care plan documentation prior to admission. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 9 The manager and or deputy assess all prospective residents at home or in hospital The homes records contained quite detailed written information, facilitating a judgement of whether the home can meet the service user needs or not. There is an established practise for initial and ongoing assessment of residents care needs. The care documents are appropriately detailed and updated. They record evidence of the contribution made by other health care professionals and the participation of the resident and their relatives. The home’s capacity to meet the residents assessed needs relies upon the skills and experience of the staff, The inspector saw records maintained by the RNs that encapsulated the overall day-to-day management of the residents care throughout the home. There is a formal system for handovers three times a day. Emergency admissions are taken subject to all assessment documentation being made available to the home prior to admission. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, The care plans identify needs and give clear directions to staff. There are good arrangements for medical cover. Residents or their relatives are consulted with about care matters and decisions about the way the home operates. Risk assessments are clear and detailed. The medication arrangements and records are in good order. EVIDENCE: Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 11 The standex system of documentation is used by the home; of those records viewed the assessments were detailed and prescriptions of the care were clearly presented. Needs were assessed using a model based on the Activities of Daily Living. At present there is no formal night plan, which is recommended. There was evidence of regular review, updating and relative / resident involvement. There were individual risk assessments including moving and handling and Waterlow assessments to assess the risk of developing pressure sores. The Stirling index of classification is used. Specialist equipment being used for individual service users i.e. alternating pressure relief mattresses / seat cushions had been recorded in the care plan. The inspector viewed the records of two individuals who had wounds; the wound care plans gave sufficient information to monitor its progress, tracings or diagrams with measurements indicated improvements. Monthly dependency levels are recorded for all residents. In future all admissions will be referred for a dental review if the individual does not have ongoing arrangements with a dentist. Health call visit regularly to carry out eyesight checks. The chiropodist visits every 6-8 weeks. The local GP visits every week and a Consultant Psychiatrist chairs a residents review meeting each month. The records indicated that staff are continuing to adhere to the appropriate procedures and practices in the home. The receipt, administration, disposal and CD records were up to date and in order other than a number of blanks noted on the MAR. None of the current residents wish to or are able to self medicate at the present time. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 A range of social and occupational activities are arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives. The food is of a high standard and provides a healthy diet. EVIDENCE: Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 13 The home has an open visiting policy. The manager and Mr and Mrs Thompson maintain regular contact with each resident and visitors when in the home. Feedback from the visitors spoken to confirmed they found the staff easy to talk to. It was evident in discussion with the staff that the individual needs and wishes of residents are considered and acted upon day to day. Two people are employed to co-ordinate social activities for 30 hours a week. Staff provide good recreational activities, which included cooking sessions, sing-along, bingo, crafts, games and gentle movement. Trips out in the community minibus are rare events due to the increasing dependency and frailty of the current residents. A number of residents go out with their families. There are celebrations for various events and festivals such as Remembrance Day, Harvest, summer fete and birthdays to which families and friends can be invited advocates and has the contact details of a number of advocacy services in the service user guide. There has not been any necessity for advocacy; if it were required the home can access The residents who were able to express an opinion stated they enjoyed their meals and felt they received the food they wanted. The meal on the day of inspection appetising and was served hot, extra portions were given to those who wanted such. There is no formal menu choice although variations are provided according to individual likes and dislikes. Liquidised diets are not served as separate elements. The only specialist diets required at present are for diabetics. All dining areas were nicely presented with the tables being set pre each mealtime. The main meal times are set, however, staff can access beverages and snacks 24hrs a day for those who would like them. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 14 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) 16,18 There are robust and comprehensive policies in place to manage complaints or allegations of abuse. There are good arrangements in place for staff training and awareness of POVA matters. EVIDENCE: The complaints procedure is on display in the home, it has contact details for CSCI. A complaints log is maintained. There have been no complaints since the last inspection. The home has adopted the RNHA policies in relation to POVA. The manager and deputy attend POVA training and cascade the information to the care staff and “Alerter” training facilitated by the Local Authority is booked for Sept. The home does has a copy of the BANES “No Secrets” or multi agency working policy. The GSCC code of practice has been distributed to the care staff. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 15 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) 19,20,21,23,26 The house is a clean, comfortable, well decorated and furnished. The home provides a safe and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. EVIDENCE: Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 16 The home is in part an older property converted and adapted to care for elderly people, with a purpose built extensions offering a total of 51 beds although at present only using 46 to reduce double occupancy. It provides care over three floors. There are two passenger lifts and a stair lift, which together give level access to all parts of the home. There are several lounge, dining and quiet areas throughout the home as it is split into three specific areas. The main building with communal areas on the ground floor, a high dependency unit on the mid floor and the new extension containing 11 beds. All areas were observed to be comfortably furnished and homely in appearance. Bedrooms and well decorated and many have been personalised. Residents had access to all communal areas in their unit. The home is smoke free environment. There are communal toilets close to the lounge and dining areas. Many of the bedrooms have en-suite toilet facilities. The home has adequate bathing areas in relation to the number of residents. One of the bathrooms contained a ½ bath and is not used. Baths have thermostatic mixer valves to monitor bathing temperatures. The home is in good order and well maintained and is fit for its purpose. There were no malodours. A maintenance person works full time at the home and can be available for emergency repairs as required. Radiators were guarded and could be individually thermostatically controlled Proper arrangements are made for the disposal of clinical waste. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 17 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) 27,29,30 The home is well staffed with appropriately trained and experienced staff. The recruitment procedures and records are in good order. Proper training arrangements and clinical updating for RN’s are in place. Good progress is being made with NVQ training for care staff. EVIDENCE: The staffing levels are in accord with the staffing notice as amended. It was agreed that the hours would be covered with immediate effect. The administrator post is now a job share and effectively full time. There are currently no nurse or carer vacancies. Ms Marsh who is an RMN and an experienced manager has filled the manager post. Ms Marsh is undertaking some additional qualifications in care of the elderly at the end of the year. The domestic, catering admin and laundry staffing levels are satisfactory. The inspector viewed the personnel records for several staff members including the recruitment of the last two employees. Staff files seen evidenced recruitment procedures were in line with the requirements. A recruitment company has been used in the past to provide care staff often from the Philippines. Enhanced CRB checks could not be viewed and these will be checked on 2nd of September a log sheet has been created for the inspector to sign and in order the disclosure can be destroyed. These checks are to be repeated every three years. Registered Nurse verification of registrations had been validated with the Nursing and Midwifery Council last year. A monthly electronic check of the NMC Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 18 list of struck off or suspended staff is carried out. A spreadsheet has been created to flag up PIN renewals and CRB re-checks. The RN training records showed evidence of recent learning and updating. Mandatory training for all staff includes fire safety, food hygiene, first aid, load handling and POVA. As recommended dementia care training is to be carried out by the manager in the near future. It is a possibility that dementia care mapping will be introduced in due course. All new staff are enrolled on a TOPSS induction programme and are linked with a mentor during their first two weeks of supernumerary shifts. All staff have regular supervision and annual appraisals have been introduced. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 19 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) 31,33,38 The home is run taking into account the views and wishes of the residents and relatives as they are able There are good arrangements in place to maintain and service the equipment and facilities in the home. The home has good Health and Safety arrangements. The staff supervision and appraisal arrangements are good. EVIDENCE: Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 20 The manager’s post has been filled and the commission has commenced a fitness assessment of Ms Marsh. See text above. As stated above an administrator has been appointed to relieve the manager of routine administrative duties. This post has now been extended to a full time job share. Mr and Mrs Thompson visit the home on a regular basis and actively support the manager. The Registered Nursing Home Association Quality/Assurance and monitoring system has been adopted by the home. The manager carries out monthly audits of health indicators and accidents. The visitors spoken to praised the home and the caring attitude of the staff. Regulation 26 reports are submitted regularly. Residents or their families are encouraged wherever possible to manage their own finances. There is an inventory of resident’s cash and valuables held for safekeeping. The inventory for the receipt or use of service user cash is endorsed by two signatures to evidence all transactions; preferably one signature being the resident although it is recognised that this is not always possible due to the disabilities of the residents. Monies were kept in a locked safe, with a limited number of key-holders to enhance security. There is a formal fire risk assessment and fire plan. The fire logbook was up to date and in order. There was a system for monitoring the risk of legionella disease. A record of hot water outlet temperatures is maintained. The gas appliances have been serviced. The electrical installation safety certificate has been updated. The lifts had been serviced and there were load test certificates for the hoists. Staff have carried out residents risk assessments and made appropriate provision to protect residents from injury. Padded bed rails are used to reduce the risk of falls where there is an assessed need and consent. There are restricted openings on windows. There are radiator covers in areas of identified risk. The home has keypad security on all doors and the Fire Exit from the top floor is now key-padded and linked to the fire alarm appropriately. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 21 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION x x x x x x x x 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 x x Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 22 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. 2. Standard 9 29 Regulation 13.2 16 & Schedule 2 Requirement Ensure an appropriate entery is made on the MAR for all medication given or omited Ensure all staff have a current CRB disclosure and make such available to the Inspector. Timescale for action From 13/07/05 by 2/09/05 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. 2. Refer to Standard 7 15 Good Practice Recommendations Prepare night care plans for all residents. Serve liquidised meals as elements not mixed. Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Cholwell House D56_D05_Cholwell_S46898_V236526_120705stage4.doc Version 1.30 Page 24 - 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. 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