Inspection on 06/09/05 for Claydon Lodge

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 05/11/07

Claydon Lodge 15/05/07

Claydon Lodge 12/12/06

Claydon Lodge 16/01/06

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 Andrew Bailey Unannounced 6 September 2005, 09:45 am 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. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 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 Martin Towle Care Home 29 Category(ies) of 29 - Older People registration, with number (Registration certificate pending for Dementia of places (18) and personal care (11)) Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18 November 2004 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. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 3.5 hours. A tour of the building took place. Discussions were held with all four of the residents, but not all of the residents had the capacity to describe how they felt about living at the home. Staff on duty were spoken with and one of the registered providers was present for part of the inspection and had discussion with the Inspector. 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). An assessment was also made of progress by the registered persons to address requirements made at previous inspections of this service. What the service does well: What has improved since the last inspection? Staff have received training in first aid. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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) 3 (standard 6 is not applicable to this service) The system for the pre-admission assessment of residents does not ensure that the needs of residents will be met. EVIDENCE: From case tracking, which included detailed examination of care plans, there was no written evidence in one of the four records to demonstrate that an up to date pre-admission assessment had been undertaken in respect of a resident who had been admitted to the home recently. This contradicts the home’s written policy and procedure for admissions, the description of the admission arrangements in the Statement of Purpose and Service User Guide, and does not meet the National Minimum Standard. Without a pre-admission assessment, there is insufficient evidence on which to determine if the service is able and suited to meet the needs of an individual resident. A member of staff on duty at the time of the inspection confirmed that the admission referred to above had not been undertaken in the required manner. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 standard(s) 7, 8 & 10 Care planning and risk assessment do not promote the safety and welfare of the residents and do not provide staff with the relevant information to guide them in meeting the needs of the residents. EVIDENCE: All four of the service users were case tracked, with reference to their care plan documentation. In one case, there was reliance on the documentation that had been compiled at a previous placement of a resident i.e. staff at this care home had not undertaken the assessments (including risk assessments) and had not formulated care plans in respect of the current needs of this resident. Whilst, the resident had only recently been admitted to the home, there was no documentation relevant to this service to guide staff in meeting the needs of the resident. In respect of the other residents, it was apparent that the reviewing arrangements were haphazard. The assessments (including risk assessments) showed insufficient evidence of monthly formal review (the latest documented reviews being in July 2005). It appeared that documentation formulated and completed by a general manager (who has subsequently ceased to be involved with the home) was of a suitable standard. Completion of documentation since Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 10 the earlier part of this year (when the general manager ceased regular contact with the home), had been inconsistent and of a generally poor standard of completion. Not all of the care plans had confirmation that the plans had been drawn up with the involvement of the resident (or representative, where applicable), so that there was no means of verifying that there was a partnership approach to care planning. The existing system does not provide meaningful information to guide staff. The records fall short of a satisfactory record of the identified needs of residents, actions to address needs of residents, and a record of the current health status of residents. Potentially this could place residents at risk (although there was no evidence at this inspection that any of the residents were at immediate risk to their welfare). A resident who was able to give an informed account praised the carers for the attention and the standard of care that they give to the residents. Staff on duty at the time of the inspection were observed to be respectful and caring in their approach to the residents. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 standard(s) 12 & 15 There is no organised social & leisure programme, but the currently small number of residents appeared content with the routines at the home. The catering service meets the needs of the residents. EVIDENCE: Staff spoken with described the informal arrangements that are 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 dart board, dice and dominoes. There were only four residents in the home at the time of the inspection. Feedback from one of the residents who was able to give an informed view was that the resident was content with the arrangements. Entertainers do not currently visit the home. One of the staff stated that the hairdresser no longer visits, since the numbers of residents do not make this viable (one of the staff has hairdressing skills and now tends to residents hairdressing needs). A member of staff felt that a more formalised programme of activities could be beneficial. The service users spoken with responded positively when asked about the meals at the home. A cook prepares meals in accordance with the known likes and dislikes of the residents. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 standard(s) 18 There are written policies and procedures for staff to follow with regard to the protection of vulnerable adults, but staff should have additional training to ensure that the protection of the residents is promoted. EVIDENCE: A member of staff spoken with described the training arrangements for adult protection. This mainly centred around the use of a training video. Some staff had previously attended training organised by Derbyshire Social Services, but this was over two years ago. It is strongly recommended that staff undertaken training from a creditable source to ensure that knowledge is up to date (for example, in respect of the reporting procedures). Use of the present video could be appropriate as part of the initial induction training of staff, prior to training from a creditable source. Derbyshire Adult Protection guidance was available on the premises. There were written policies and procedures for abuse and for the use of restraint. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 standard(s) 19 & 26 There are issues with the maintenance arrangements, which result in the environment for the residents having defects that are not always dealt with promptly. EVIDENCE: A member of staff stated that there had been difficulties getting repairs carried out in a timely manner. There was reportedly sometimes a problem with the availability of the maintenance person/service personnel. Some tasks had not received attention at the time of the inspection, such as a broken sluice machine, which meant that staff had to dispose of waste in an alternative area. A broken glass pane in a ground floor window also awaited repair (although this area is not registered, there could be security implications for the registered part of the premises). Several lights needed attention (either blown or flashing). Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 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 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 &30 The staffing is proportionate to the needs of the number of residents currently accommodated in the home. The staff training programme does not ensure that competent staff meet the needs of the residents. EVIDENCE: Three of the residents responded positively when asked about the care that the staff deliver and one of the residents said that the care staff are excellent and very friendly. The staffing rotas were examined and it was apparent that the staffing levels are satisfactory and proportionate to the number of residents currently living at the home. A member of staff spoken with at inspection had been involved on the second of two days of the induction of a member of care staff who had recently commenced at the home. It was apparent that a previous requirement for staff training to be in accordance with recognised workforce targets had not been carried out i.e. there was no written induction programme for the supervisor and employee to complete on the day in question that senior member of staff was referring to. There was no evidence at inspection of a training programme that met Skills for Care (training body) targets. This does not provide satisfactory assurance that the training arrangements protect residents. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 15 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) 33, 36 & 38 There are no formal systems in place for staff supervision, to ensure that competent staff meet the needs of residents. There are no quality systems to endorse that the service is run in the best interests of the residents, and with an emphasis on improvement. Some of the safe working practices training has lapsed, which potentially puts the safety of the residents at risk. EVIDENCE: Whilst the Service User Guide and Statement of Purpose describe quality related activities, there is no evidence in practice that quality systems are utilised to measure satisfaction with, or effectiveness of, the service. For example there were no satisfaction survey results to refer to. Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 16 There are no arrangements for regular and organised staff supervision. Staff spoken with stated that appraisal forms were distributed some time ago, but no formal and documented supervision of staff takes place. There are outstanding requirements to introduce a quality assurance system, staff supervision and a suitable staff training programme. Following discussion at inspection with one of the registered providers about the management arrangements at the home the timescales for achieving the requirements have been extended. There was a requirement at the last inspection for staff to receive first aid training. This requirement has been complied with. However, it was ascertained that fire safety training (& drills) is now out of date and manual handling training is also now due. Some staff had watched a fire-safety video, but this was not supported by formalised training (and drills) led by a trainer who had received regular updates from a creditable source (such as the fire service). Examination of the fire log supported that training is out of date. A requirement has been made to ensure that safe working practices training is arranged promptly to promote resident safety. The registered provider spoken with at inspection stated that he would be making arrangements for the electrical installation testing to be carried out in the near future (now due for re-testing). Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 17 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 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 1 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 1 x x 1 x 2 Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 18 yes 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 3 Regulation 14 (1) Requirement New service users must only be admitted to the home following an up to date assessment completed by a suitably qualified or experienced person, with confirmation in writing that the home can meet the needs of the service user There must be evidence of service user/representative involvement in the drawing up and review of care plans Comprehensive care plans must be prepared and be regularly reviewed for all service users (including appropriate risk assessments) There must be an efficient system in place for addressing routine maintenance at the home The broken external glass door panel must be replaced (security issue) the sluice machine must be repaired/replaced The registered person must ensure that there is a staff training and development programme in accordance with recognised workforce training C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Timescale for action 30 September 2005 2. 7 15 (1,2) 31 October 2005 30 September 2005 31 October 2005 31 October 2005 30 September 2005 30 November 2005 3. 7 15, 17 4. 5. 6. 7. 19 19 26 30 23 (2) 23 (2) 23 (2) 18 Claydon Lodge Version 1.40 Page 19 8. 33 24 (1) 9. 36 18 10. 11. 38 38 13 (5) 23 (4) targets and individual staff training needs assessment profiles (previous requirement timescale of 18/02/05 not met) The registered person must ensure that the home has a quality assurance system with a systematic cycle (previous requirement - timescale of 18/02/05 not met) The registered person must ensure that care staff receive formal supervision sessions at least six times per year (previous requirement timescale of 18/02/05 not met) Staff must receive moving and handling refresher training Staff must receive fire safety training and undertake drills at intervals not exceeding those recommended by the fire officer A valid certificate for the electrical installation must be obtained 30 November 2005 30 November 2005 31 December 2005 30 September 2005 31 December 2005 12. 38 13 (4) 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 12 18 Good Practice Recommendations A programme of activities & events should be arranged for the service users Staff should receive refresher training on adult protection from a creditable source e.g. by attending social services training Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection South Point, Cardinal Square Nottingham Road Derby DE1 3QT 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 Claydon Lodge C02 C52 S20213 Claydon Lodge V245790 060905 Stage 4.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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