Inspection on 05/11/07 for Claydon Lodge

This inspection was carried out on 5th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Claydon Lodge 06/10/09

Claydon Lodge 15/05/07

Claydon Lodge 12/12/06

Claydon Lodge 16/01/06

Claydon Lodge 06/09/05

Claydon Lodge 18/11/04

Claydon Lodge 19/07/04

Claydon Lodge 27/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Claydon Lodge Crich Place North Wingfield Chesterfield Derbyshire S42 5LY Lead Inspector Bridgette Hill Unannounced Inspection 5th November 2007 09:15 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 DS0000020213.V352256.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. DS0000020213.V352256.R01.S.doc Version 5.2 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) stephen@claydonlodge.co.uk Mr Diwan Chand Dr. Anjuman Diwan Chand Manager post vacant Care Home 29 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (11) of places DS0000020213.V352256.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The provider is registered to provide personal care and accommodation for service users whose primary care needs fall within the following category:- Old age, not falling within any other any other category (OP) 11, Dementia over 65 years of age (DE(E)) 18 The maximum number of persons to be accommodated at Claydon Lodge is 29. This registration to be seen only as phase 1 (as outlined in letter dated 9/12/04) of the full application of the home. 24th July 2007 2. 3. Date of last inspection 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 service users. The registered accommodation is on the first floor of the building. The ground floor accommodation is not registered however there is currently building work underway in this part of the home. The range of fees charged at the home are £325.05 - £343.20 per week with extra charges made for Chiropody, toiletries and newspapers. The Acting Manager at the inspection gave this information. The most recent key inspection report was available in the entrance hall. There had been some work completed to update the Statement of Purpose and Service User Guide but some detail regarding the provision of social and leisure activities was still required. DS0000020213.V352256.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced visit which focused on assessing compliance to previously listed requirements and on assessing all key standards. As part of the inspection a sample of service users care files and a range of documents were examined. A tour of the building was conducted. During the visit opportunity was taken to have discussions with management, 1 relative and 2 service users. Some service users were unable to give their opinions due to having dementia. Prior to the inspection an Annual Quality Assurance Assessment form was completed by the Acting Manager, where relevant details of this have been included in the body of the report. Surveys have also been sent to all 5 service users and relatives. Three surveys were returned from service users (who were assisted by relatives or their representatives to complete the form) and 2 from relatives, comments and findings are included in the body of the report. The person in charge at this visit was the Acting Manager Stephen Booker What the service does well: What has improved since the last inspection? There has been significant progress made in a range of areas since the last inspection. This included the recruitment procedures in place and the level of training staff had received. Staff were also receiving supervision from the Acting Manager. There had been work done to improve the homes quality assurance processes with the Provider recording monthly visits to the home which include talking to staff and service users. A key worker system has been introduced and some risk assessment tools have been added to the care planning documents. Some improvements had been made to the environment with a new staff call system, lighting and washer being installed. DS0000020213.V352256.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000020213.V352256.R01.S.doc Version 5.2 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 DS0000020213.V352256.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst there have been no admissions since the last inspection there are systems in place to ensure service users needs are assessed prior to them being admitted to ensure the home can meet their needs. EVIDENCE: There had not been any new admissions to the home since the last inspection. The Acting Manager said that they always visited prospective service users before offering admission to the home. The Annual Quality Assurance Assessment received from the home indicated that a new pre admission assessment tool had been introduced. The sample of existing service users files seen indicated that information from Social Services was available including assessments and ongoing reviews whilst service users were in the home. DS0000020213.V352256.R01.S.doc Version 5.2 Page 9 The most recent key unannounced inspection report was available in the entrance foyer and a copy was available in the office. The Statement of Purpose and Service User Guide had been updated and were improved as regards the information they contained. The Statement of Purpose did not include what the home offered service users to meet their social and The home does not offer intermediate care as defined by National Minimum Standards 6. DS0000020213.V352256.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are care plans in place for each service user that are reviewed and personalised to describe how their needs are to be met. EVIDENCE: A sample of two service users care files were examined to assess how standards were being met. Some were assessed in part to explore different aspects. The care plans in place were typed and easy to read. They were detailed on how staff should approach and care for individual service users. Care plans reviews had been documented on a monthly basis. Staff wrote the ongoing log records on a shift-by-shift basis. Since the last inspection a key worker system has been introduced with a clear list of responsibilities for staff to complete. There were notices in service users DS0000020213.V352256.R01.S.doc Version 5.2 Page 11 bedrooms to inform them who was their allocated key worker. Service users or their representative had signed the care plans seen. Some risk assessment tools were included in the care planning documentation, these included tissue viability, nutrition and Moving and handling. There were no documented reviews of the scoring of these forms but the Acting Manager said they were considered as part of the monthly care reviews. There were identified thresholds where referral to healthcare professionals would be instigated. Service users weights were recorded on a monthly basis. There was established provision of optical and chiropody services with professionals visiting the home on a regular basis. Care plans included details of GP visits as well visits from other healthcare professionals and communication with relatives. The home does not provide nursing care. This is provided through the District Nursing service if it is assessed as being required. The Acting Manager reported a good working relationship with the District Nurses. The storage and administration of medicines was examined at his visit. The home uses a monitored dosage system and generally uses printed medication administration records supplied from the pharmacy. There were records to indicate what medications had been received into the home and what had been returned to pharmacy. Two staff signed some, but not all handwritten medication administration records. No gaps were evident and all medications that were prescribed were signed as administered. Charts were in place to indicate where prescribed creams were to be administered. The drug reference book available was dated 2004. Service users spoken to said that staff positively regarded their dignity when delivering personal acre. One service user said that staff ‘helped them with things they couldn’t do’. DS0000020213.V352256.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Following consultation with service users a limited range of activities are offered there is however scope to improve the provision to enhance service users choice and lifestyles. EVIDENCE: Since the last inspection some work had been completed on trying to get service users family histories and asking about their social and leisure preferences. A new sheet had been introduced to record any activities that service users were offered and involved in. Service users religion had also been included in the care planning documents. The type of activities service users participated in was some crafts, walks out in the local community and washing dishes. Staff were observed to be friendly and welcoming to visitors and readily offered drinks. The surveys received from relatives indicated that there was good communication from staff at the home if there were any concerns regarding the service users. DS0000020213.V352256.R01.S.doc Version 5.2 Page 13 Service users spoken to said the food at the home was good. There were plans to review the menu particularly the vegetarian menu but this had not yet been completed. The records indicated that the choice of vegetarian foods offered remained limited with a high frequency of quorn served. Observations were made of a staff member helping a service user with lunch this was done sensitively and patiently. The Annual Quality Assurance Assessment completed by the Acting Manager indicated that menu choices could be better. DS0000020213.V352256.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to ensure a consistent approach to any complaints and Safeguarding Adults concerns were handled consistently and service users are listened to. EVIDENCE: The Commission for Social Care Inspection had received one complaints since the last inspection on 24th July 2007, this was referred to Social Services who funded the service user concerned. There were records at the home to indicate that this had promptly been investigated and a written response had been sent. An open invitation to the complainant to meet and discuss the findings had been extended. A complaints procedure was available which included the address of the Commission for Social care Inspection. The relative spoken to said the Manager was approachable if they had any concerns. Surveys from relatives indicated that they had not had any reason to complain but knew how to if they needed to. There have not been any investigations relating to safeguarding adult concerns since the last inspection. DS0000020213.V352256.R01.S.doc Version 5.2 Page 15 Training records indicated that staff had received Safeguarding Adults training. A policy and procedure was in place on how to deal with allegations if they are made. This referred to locally agreed procedures with Social Services taking the lead. A whistle blowing policy for staff was also available. DS0000020213.V352256.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment of the home is considered adequate and clean with general maintenance undertaken some investment is required to ensure it maintained to a comfortable standard for service users to live in. EVIDENCE: The home is a purpose built one in a quiet cul de sac within walking distance of the GP surgery and local shops. Only the upstairs of the home is currently being used as a care home with all service users rooms being on this floor. The laundry and kitchen are situated on the ground floor. A lift is available for service users with mobility problems. Some picture and photograph signs were in place to help orientate service users to bathrooms and their bedrooms. Significant building work was underway on the ground floor of the home which is currently not registered as a care home. This has caused some disruption to DS0000020213.V352256.R01.S.doc Version 5.2 Page 17 existing service users with noise and dust but has been kept to a minimum wherever possible. The occupancy of the home is low and large parts of the home are not currently being used. One lounge and dining room is currently used. Some aspects of the décor are showing signs of wear for example bed linens and curtains were particularly faded and there were occasional areas of paint work and borders that required attention. A large garden area was available and the grass had been cut back but access for service users was limited as it was not secure and there was scope to improve the garden area with planting, seating and ensuring it is safe and secure for service users to use. A work place fire risk had been developed since the last inspection and the fire alarm and equipment had been serviced at suitable intervals. The home was found to be clean and fresh and domestic staff were employed. A handyman is employed who is shared with a sister home who undertakes general maintenance jobs. Since the last visit new lighting has been fitted in corridors that has improved the brightness and incorporates an emergency lighting system. A new staff call system has also been fitted. The laundry area was on the ground floor and since the last visit a new washer had been installed. One service user said they were happy with the laundry service. Care staff currently did the laundry in the home. DS0000020213.V352256.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are recruited, inducted and trained appropriately and a good staff to service user ratio is evident to ensure service users needs can be met EVIDENCE: The occupancy of the home on the day of the visit was 5 service users. The home provides personal care only with nursing care being provided through the district nursing service. The typical staffing levels at the home were 2 care staff for all shifts including nights. The Acting Manager worked some shifts on a supernumerary basis but did work some shifts as part of the care team. Some agency staff were being used and the Acting Manager said that were possible the same staff were requested to ensure there continuity of care given to service users. From the records at the home it was found that were 12 care staff employed at the home of which 5 held NVQ (National Vocational Qualification) level 2 or above in care qualifications. Discussions with the Acting Manager confirmed that an additional 6 staff had begun NVQ (National Vocational Qualification) courses. DS0000020213.V352256.R01.S.doc Version 5.2 Page 19 A sample of two staff files were examined to assess how recruitment procedures were being followed. The files seen at random indicated that all required checks had been competed and were in place. Sometimes staff had started work with a Pova first check in place whilst a full Criminal records Bureau check was being processed. Notes from interviews were on file along with copies of training certificates that staff had completed whilst in previous employments. A sample of the staff training files were examined. These were up to date and indicated that a range of training had taken place since the last inspection. Training completed included: First Aid, basic food hygiene, Safeguarding Adults, Moving and handling, fire and medication. Further training dates were planned for Health and Safety, fire safety and optical care. New staff that started completed a checklist induction and a skills based induction pack was also available. A partly completed example of this was seen during the visit. DS0000020213.V352256.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is evident that there has been an improvement in the management of the home and systems and work has been undertaken to improve the service received by service users. EVIDENCE: An Acting Manager has been in post at the home since May 2007 and has submitted an application to formally register as Manager with the Commission for Social care Inspection. This is currently being processed. The Manager in post said they had achieved their Registered Managers Award and had experience of managing other care homes. DS0000020213.V352256.R01.S.doc Version 5.2 Page 21 A relative and service users spoken with spoke positively of the Manager and reported that there had been improvements since they had been in post. A warm, jokey, leg-pulling relationship was evident between the Manager and service users. Discussions and examination of quality assurance processes were examined. The Provider had begum to complete monthly recording of their visits to the home. The notes kept included discussions with staff and service users to establish their views of the home. Two surveys from GP’s had been completed. One raised the issue of when the home contacted the surgery advising that mornings are best to request visits, the Acting Manager said that this was now being done. One staff meeting has been held since the last visit and this documented a range of issues were discussed including some relating to good practice. No service users had money being stored safely in the home though forms for recording this were available if service users chose to use this facility. Staff supervision records were examined. These confirmed that a planner was in place to indicate when supervisions were due and completed records of staff supervisions that had taken place were seen. The service records for the home were examined, these were kept in an ordered file and the records indicated that all equipment and fixtures had been serviced at appropriate intervals. The temperature of water in baths and showers were being checked and recorded on a weekly basis and were all at acceptable temperatures to prevent scalds. Accidents records were kept and any actions taken were recorded. DS0000020213.V352256.R01.S.doc Version 5.2 Page 22 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 2 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x N/A 3 x 3 DS0000020213.V352256.R01.S.doc Version 5.2 Page 23 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 OP2 Regulation 4&5 Requirement The Statement of purpose and Service User Guide must be up to date and made available to service users to ensure they have sufficient information regarding the home Work has been commenced but some amendments still requirement timescale extended. Previous timescale 31/07/07 2 OP31 8 The registered person must ensure that a registered manager is in post Previous timescales 30/06/07 & 30/08/07 Application submitted to Commission for Social care Inspection and being processed – timescale extended accordingly 30/11/07 Timescale for action 30/11/07 DS0000020213.V352256.R01.S.doc Version 5.2 Page 24 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 4 Refer to Standard OP8 OP9 OP9 OP15 Good Practice Recommendations Where risk assessment tools are used a system of reviewing the scoring of these should be introduced at varying frequency relating to the service users needs Where medication administration records are handwritten these should be checked and verified by two staff members A drug reference book not dated mor4 than 1 year old should be obtained The vegetarian menu should be reviewed in consultation with service users to ensure that this is varied and appealing Service users should be given choices of food and consulted regarding the menu offered Consideration should be given to bed linen and curtain replacement and redecoration of the home to ensure it is maintained to an acceptable standard 5 OP19 DS0000020213.V352256.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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