CARE HOMES FOR OLDER PEOPLE
Claydon Lodge Crich Place North Wingfield Chesterfield Derbyshire S42 5LY Lead Inspector
Andrew Bailey Unannounced Inspection 16th January 2006 14:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Claydon Lodge Address Crich Place North Wingfield Chesterfield Derbyshire S42 5LY (01246) 852435 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) Mr Diwan Chand Dr. Anjuman Diwan Chand Mr Martin Towle Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Claydon Lodge Care Home is located in the village of North Wingfield, which is to the south east of Chesterfield. The home is purpose built and it is registered to provide personal care for up to 29 elderly persons. The registered accommodation is on the first floor of the building. The ground floor accommodation is not registered. Registration certificate pending for Dementia (18) and Personal Care (11) Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the duration of the inspection was approximately 3 hours. A tour of the building took place. The Inspector met the residents during the inspection. Whilst the residents were not able to describe how they felt about the care and services, they appeared to be at ease in the home. There were no relatives available to speak with. A number of records were examined during the visit, including care plans as part of the case tracking process, which is used to help determine how the home meets the needs of individual residents. The focus of this inspection was on key National Minimum Standards and the requirements from the last inspection of this service were also assessed. What the service does well: What has improved since the last inspection?
The documentation for pre-admission assessment has been developed and the care plan review process has been updated to facilitate reviews at monthly intervals. The process for addressing maintenance issues has been reviewed and a number of maintenance/service matters that were outstanding at the last inspection have been attended to. Preparations have been made to align the staff induction programme with recognised workforce training standards and a supervision system has been commenced. There have been some mandatory training updates since the last inspection. A survey of resident/representative satisfaction has taken place since the last inspection, with feedback on the survey findings made available. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 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. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 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 the following standard(s): 3 Systems have been improved to provide pre-admission assessment of residents to assure that the home is able to meet residents’ needs. EVIDENCE: A previous requirement to ensure that the needs of residents are assessed prior to admission had been addressed by the development of pre-admission documentation. Although there had been no further long-term admissions to the home since the last inspection, the documentation had been used to assess the needs of a short-stay resident. The documentation for this resident was examined at this inspection. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Staff do not always have clear and specific written guidance to follow in order to meet residents’ care needs, and care cannot always be evaluated easily. The system for recording medication does not provide a sufficiently robust audit trail and there must be periodic competency based training for all staff administering medications to promote the safety of residents. EVIDENCE: The review process for care plan documentation has improved since the last inspection, with documentation introduced for recording the monthly review of care plans. The care plans of three residents were examined at this inspection. There was some inconsistency in recording the action to be taken by staff to meet the needs of the residents. This was largely related to the lack of clear links between the outcomes of risk assessments e.g. falls and tissue viability, and the individual care plans for each resident. In some instances risk assessment scores indicated the existence of risk, but there was no corresponding care plan developed to address the identified risk. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 10 There appeared to be some confusion as to what constituted a problem, a goal, and intervention in respect of the care needs of residents. This was discussed at this inspection and it is recommended that a review of each resident’s care plan be undertaken to ensure that these areas are properly documented. It was noted that the persons undertaking the monthly reviews had not signed all of the evaluations. Overall, there was inconsistency in the signing of care documents. This lessens the value of the records in legal terms. In general, there had been some improvement in the standard of care plan records since the last inspection. An examination of the medication systems took place at this inspection. One area to address is the need for a robust audit trail of medication entering and leaving the home. Receipts of medication were not consistently documented i.e. confirmation of amounts, with an accompanying signature. Some examples of the documented returns of medication were not dated and signed by staff at the home. A second area for attention is to ensure that all staff that hold responsibility for administering medication have received competency based training. The training must be supported by periodic updates. There was no record of training to meet this standard. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14 There is no organised social & leisure programme to meet individually assessed needs of residents. Staff appreciate the importance of maintaining choices for the residents in their daily lives. EVIDENCE: There are only informal arrangements provided to meet the social and recreational needs of the residents. Examples are: a miniature snooker table (in one of the communal lounge areas), TV, music, a magnetic dartboard, dice and dominoes. There had been events at the home for Bonfire Night and over the Christmas period, but the small number and capabilities of the current residents has been viewed as a limiting factor in providing an active social programme. The manager stated that there were plans to formalise the programme to provide at least one daily event for the residents. None of the current residents have the capacity to lead fully independent lives. Staff support the residents in decision-making and encourage choices as far as possible. The residents have been encouraged to bring in personal possessions to personalise their bedrooms. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 A complaints procedure is in place and this is displayed for residents or their representatives to refer to. There are written policies and procedures for staff to follow with regard to the protection of vulnerable adults, but not all staff had yet undertaken additional training to ensure that the protection of the residents is promoted. EVIDENCE: There had been no complaints raised since the last inspection of this service. The complaints procedure is made available to residents/representatives and is displayed within the home. Derbyshire Adult Protection guidance and reporting documents are available in the home. Protection of Vulnerable Adults guidance is also available (this includes details about referral to the POVA list and good recruitment practices). The registered manager stated that some staff had attended local authority training on adult protection recently, but arrangements need to be made for the remaining staff to receive this training. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 The system for dealing with routine maintenance issue has improved since the last inspection, providing better-maintained premises for the residents. There is a health and safety issue to address to minimise risk to residents. EVIDENCE: A Health & Safety Inspector visited the home within the last few months. The report identified that some first floor windows could be opened sufficiently wide that this could present risk to vulnerable residents. This must be addressed as a matter of urgency, especially given the needs and dependency of the current residents. It is usual to restrict the opening of first floor windows to a maximum of 100mm in this type of setting. The sluice machine, out of order at the last inspection, had been repaired. A ground floor glass panelled door had also been repaired. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 Some of the care staff have undertaken NVQ training, which promotes the safety and welfare of the residents. An induction programme that meets recognised standards has been obtained, but there are insufficient records of staff training held on-site to verify that residents are protected by the training of staff. EVIDENCE: The registered manager reported that six staff have obtained National Vocational Qualification (NVQ) Level 2 or 3, with three staff not having trained to this level. A sample of personnel information was examined at this inspection and it was confirmed that Criminal Records Bureau Disclosure clearance had been obtained. There was a previous requirement to ensure that there was a training and development programme that met nationally recognised standards. A ‘Skills for Care’ programme has been obtained. This has not been introduced, there having been no newly appointed members of staff. It is recommended that all current staff work through this, given that there have been shortfalls in the induction mechanisms in the past. There must be records kept on-site, and available for inspection, to confirm that staff have received on-going training e.g. mandatory training. These may be copies of original certificates, if staff wish to retain the original documents.
Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 15 There is currently insufficient evidence of staff training maintained for the inspection process to verify the arrangements. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The manager must undertake recognised training to meet the required conditions for managing a care home. Additional quality systems must be instigated to support that the service is run in the best interests of the residents, with an emphasis on improvement. Some routine servicing is out of date and evidence of certification of other servicing is required to further assure that residents live in a safe environment. EVIDENCE: Managers of care homes (personal care) are required to hold a National Vocational Qualification (NVQ) Level 4 in management and care (or accepted equivalent qualifications). This is to ensure that qualified, competent and experienced persons manage care homes (National Minimum Standard 31.1). The manager is experienced, but does not currently hold these qualifications. A timescale for the requirement has been issued, in line with current CSCI guidance on the latest completion date. The manager must enrol for training
Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 17 for the required qualifications at the earliest opportunity (timescale of 31/03/06 given). Staff confirmed that one of the registered providers regularly visits the home. However, there were no recent written reports as a result of provider visits (required in accordance with Regulation 26 of The Care Homes Regulations 2001). A quality assurance tool had been prepared for use at the home, but this had not been instigated. As such, there was no evidence of formalised routine and on-going monitoring of the service by the registered persons. On a positive note, there had been a survey of satisfaction since the last inspection. The current residents are limited in their capacity to give informed feedback and therefore the representatives of residents’ had been involved in the survey. Written feedback was available; this had not been incorporated into the Service User Guide. There were satisfactory records of residents’ monies held for safekeeping, but it is recommended that reconciliation checks of amounts be documented periodically for audit purposes. A system of staff supervision had been introduced since the last inspection of this service. There had been mandatory training for staff since the last inspection e.g. fire safety (the certificate/training record for this training was available at inspection). Some of the mandatory training had been undertaken on a distance-learning basis. The manager reported that the electrical installation had been inspected in December 2005 (previous requirement), but there was no certificate available to verify the status of the inspection findings. This must be obtained and a copy provided to the CSCI. The Portable Appliance Testing labels indicated that the last testing was undertaken in October 2004. This testing must be carried out without delay. A valid Landlords Gas Safety Certificate was available at inspection. Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 14, 15 Requirement Care plans must clearly set out the detail of action that needs to be taken by staff; For example, to meet needs identified from risk assessments Staff administering medication must receive periodic competency based training There must be a robust audit trail of medications, to include confirmation of medicines received into the home and medicines disposed of (or returned) The findings of the latest Health & Safety inspection of the home must be addressed (with priority to ensuring that all first floor windows have suitable window restriction) There must be records available for inspection to provide evidence of staff training e.g. copies of course certificates The registered manager must attain qualifications at Level 4 NVQ in both management and care. The manager must enrol for these qualifications by
DS0000020213.V278000.R01.S.doc Timescale for action 31/03/06 2 3 OP9 OP9 13 (2) 13 (2) 31/03/06 28/02/06 4 OP25 13 (4) 28/02/06 5 OP30 18 (1) 31/03/06 6 OP31 9 30/09/07 Claydon Lodge Version 5.1 Page 20 7 OP33 24 (1) 8 OP38 13 (4) 9 OP38 13 (4) 10 *RQN 26 31/03/06. (Timescale follows current CSCI guidance for the latest acceptable completion date). The registered person must ensure that the home has a quality assurance system with a systematic cycle (previous requirement - timescales of 18/02/05 & 30/11/05 not fully met) Portable Appliance Testing of electrical equipment must be carried out annually (last undertaken Oct 2004) A valid certificate for the electrical installation must be obtained (previous timescale of 31/12/05 not met). Test apparently completed, but no certification available on-site (copy to be provided to CSCI by the timescale) The registered provider(s) must prepare written reports of visits to the home in accordance with Regulation 26 of The Care Homes Regulations 2001 31/03/06 31/03/06 28/02/06 28/02/06 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 3 Refer to Standard OP7 OP7 OP12 Good Practice Recommendations There is more than one format of care plan in use. The processes should be reviewed to provide a standardised system of documentation of care needs All care plan entries should be signed by the person making the entry A programme of activities & events should be arranged for the service users (recommendation from previous inspection)
DS0000020213.V278000.R01.S.doc Version 5.1 Page 21 Claydon Lodge 4 5 6 7 OP18 OP30 OP33 OP35 Staff should receive refresher training on adult protection from a creditable source e.g. by attending social services training (Some staff still to attend, as of 16/01/06) There should be records to support that care staff currently employed have undergone recognised induction training Feedback to service users/prospective service users on the summary results of satisfaction surveys should include published findings for inclusion in the Service User Guide There should be periodic documented reconciliation checks of the monetary amounts held on behalf of service users (personal monies), for audit purposes Claydon Lodge DS0000020213.V278000.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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