Inspection on 17/01/07 for The Chapel House

This inspection was carried out on 17th January 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 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

The Chapel House 28/01/09

The Chapel House 28/02/06

The Chapel House 04/10/05

The Chapel House 16/02/05

The Chapel House 05/08/04

The Chapel House 11/02/04

The Chapel House 04/11/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Chapel House Chapel House Chapel House Lane Puddington South Wirral CH64 5SW Lead Inspector Joan Adam Unannounced Inspection 09:30 17 January 2007 th 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 The Chapel House DS0000018713.V320761.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. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chapel House Address Chapel House Chapel House Lane Puddington South Wirral CH64 5SW 0151 3362123 0151 3363833 thechapelhouse@tiscali.co.uk 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) Mrs Imelda Moore Cathrina Moore Care Home 35 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (35) of places The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The home is registered for a maximum of 35 service users to be accommodated in the category DE(E) (Dementia over the age of 65 years) Within the overall number of service users to be accommodated, 2 named service users may be accommodated in the category DE (Dementia under the age of 65 years) The registered provider must provide staff to meet the dependency levels of service users, including 3 day care, at all times and shall comply with any guidelines which may be issued through the Commission for Social Care Inspection 28th February 2006 Date of last inspection Brief Description of the Service: The Chapel House is located in the village of Puddington to the north west of Chester, and is surrounded by farmland and countryside. The home is a family business, with the proprietors involved in the day-to-day running of the home. The building is a three storey detached country house which has been extended and adapted by the present owners. The home has two lounges each providing access to conservatories that are used as dining rooms and for social activities. There is a passenger lift providing access to all three floors, however six of the bedrooms can only be accessed by a short flight of steps on the first floor. There are enclosed and secure gardens with access for ambulant residents and wheelchair users. The home is registered to provide nursing care for 35 older people with dementia related needs and also provides day care services for up to three people. At all times there is a registered nurse and care staff on duty. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place on 14th January 2007 and took six hours. It was carried out by an inspector of the Commission The visit was just one part of the inspection. The home was not informed of the date the visit was to take place, but a few weeks prior to the visit the manager was asked to complete a questionnaire to provide the inspector with some information about the service. The manager was also asked to distribute questionnaires to residents, relatives and health and social care professionals to help the inspector find out what they think of the home. Seven responses were received from relatives. All were positive about the standard of care in the home. The residents living at the Chapel House were unable to make comments about the care they received due to the nature of their illness. Comments made by relatives and friends of people living at the home have been incorporated in to the report. During the visit the inspector spoke with the manager, staff, residents and visitors. The premises and various records held by the home were looked at. Feedback was given to the registered manager at the end of the inspection. What the service does well: The home is well managed and provides good care to the residents living there. There is a quality assurance system in place which gains the views of the residents and their relatives.” The meet and speak evenings are particularly good. Views are varied” Full and comprehensive assessments are carried out and care plans are in place to ensure the home will be able to meet the residents’ needs. There is a good, friendly relationship between staff and residents and staff are mindful of service users’ privacy and dignity. Residents and staff said that the management of the home is open and positive. One comment card said “ the chef is excellent and the meals are varied and the veg. is fresh” The home is very well maintained and clean. It provides a comfortable and welcoming environment. Visitors are warmly welcomed into the home. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 6 Comments such as “ mum has high standards and I feel that Chapel House meets these standards” What has improved since the last inspection? 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. The Chapel House DS0000018713.V320761.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 The Chapel House DS0000018713.V320761.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. Assessments of people’s care needs are carried out before they move into the home so that residents know their needs can be met. EVIDENCE: The files of two newly admitted residents who had moved into the home in recent months were looked at. It contained assessments of dependency levels, mental health needs and likes and dislikes. There was evidence that relatives had been involved in the pre admission process. The pre-admission assessments had been carried out by the manager or a senior member of staff. The home is not registered to take residents with intermediate care needs. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are met by staff who enable them to maintain their privacy and dignity. EVIDENCE: The care plans of four residents were looked at. Care plans identified areas of need such as pressure area care, mobility, continence, nutrition, mental health needs and general dependency. The care plans contained sufficient information to provide care staff with the necessary information for them to look after a person’s needs. There was written evidence to confirm that care plans were being reviewed and evaluated regularly. The care plans seen showed that there had been consultation with residents or their families/advocates. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 10 However, one care plan in place for a resident with a pressure sore did not describe the type of dressing to be used and how often it should be changed. The care plan did not describe the grade, size, colour and depth of the pressure sore to enable staff to measure the improvement or deterioration of the wound. The atmosphere at the home was warm and friendly and the staff interaction with residents reflected good positive relationships. Staff were heard to address the residents appropriately explaining to them what they were going to do when using hoists and to maintain their dignity and privacy when providing personal care to them. Relatives said that “ the staff are really good and treat the residents with respect.” “ the staff are hard working and are very good” “ the staff are lovely, the trained staff are professional and I am always informed of any changes to my relatives condition.” Medication management and storage arrangements were looked at. The home used a monitored dosage system. Medication administration records were not completed correctly with unexplained gaps so staff may be unaware if the resident has received the medication. Medicines were stored correctly. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living and activities available are flexible and varied to suit residents’ expectations, preferences and capacities. EVIDENCE: The home employs an activities co-ordinator. Activities on offer are manicures, hairdressing, sing-a -longs, bingo, reminiscence, exercise to music and one to one sessions with residents to read newspapers or magazines. Outside entertainers are booked at the home on a regular basis. One relative was discussing the family day which takes place just before Christmas to enable all family members to visit the home and exchange presents whilst enjoying a party with their relative. Relatives said that they are always made welcome at the home. Religious preference is recorded in the care plan and ministers from the local churches visit the home regularly to hold services. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 12 Menus are varied and offer choice and nutritious meals. The dining rooms at the home are situated in the conservatories and the atmosphere at lunch time was calm and pleasant. Residents and relatives said that the food at the home was very good. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 13 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. There is a complaints procedure in place and the residents are protected from abuse. EVIDENCE: The home’s complaints procedure provides appropriate guidance and information as to how to make a complaint. There have been no complaints made to the home or CSCI since the last inspection. A copy of the complaints procedure is displayed on the wall in the lounge. The home has an Adult Protection procedure (including Whistle Blowing), which complies with the Public Disclosure Act 1998 and the Department of Health Guidance “No Secrets”. The staff receive on going training on adult protection from the deputy manager. Both staff members and the home’s training records confirmed this. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The Chapel House provides a comfortable environment for those living there and visiting. EVIDENCE: A partial tour of the home was undertaken. All the shared areas and a selection of bedrooms were seen. A good standard of décor was evident and the home was furnished to a good standard. A good standard of décor was evident. Bedrooms were well personalised with residents’ own furniture, picture and ornaments. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 15 During the last year a new sluice machine has been fitted on the top floor of the home. Decoration has been on going and bedrooms throughout the home have been decorated. Corridor carpets and curtains have been replaced on the first and second floors. A new shower room has been created on the ground floor to enable residents to have a choice as to whether they have a bath or shower One of the lounges has had a partition wall removed to give more space within this room. All lights throughout the home have been fitted with low energy light fittings. The emergency lights have been upgraded to maintain the safety of the residents. New lounge chairs have been purchased. New windows have been ordered and will be fitted within the near future. The home was cleaned to a high standard on the day of the site visit. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 16 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. Staffing levels and skill mix are sufficient to meet the needs of the residents, Residents are protected by the home’s recruitment practices and staff training. EVIDENCE: There were adequate numbers of staff on duty to meet the needs of the residents living at the home. The home has an on going training programme and copies of courses undertaken were seen on the training matrix. Training undertaken by staff is moving and handling, health and safety, fire awareness, first aid, food hygiene and protection of vulnerable adults. A training programme is in place to enable staff to achieve NVQ level two in care. Over fifty per cent of care staff are qualified in NVQ level two and all senior carers are qualified in NVQ level three. Staff files were looked at for three newly employed staff members and all of these contained appropriate checks prior to commencement of employment. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 17 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. The health, safety and welfare of the service users are protected. The views of service users are obtained to influence the running of the home. Staff are fully supervised EVIDENCE: The manager of the home is a registered general and mental nurse and is an experienced manager. She is registered with CSCI and has completed the National Examination Board of Supervisory Management. The deputy manager has achieved the registered managers award. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 18 Relatives spoken with said that they felt the home was well run and that the manager and staff were very welcoming and friendly. Staff at the home are supervised on a daily basis and formal supervision was given on a regular basis. Residents’ finances are recorded appropriately and receipts of any purchases are kept. The home has responsibility for four of the residents’ finances. The maintenance records demonstrated that the appropriate service contracts were in place. These included the passenger lifts, hoists and fire alarm system. A quality monitoring system is in place and questionnaires are given to residents and relatives to gain their views on the home. Resident, relative and staff meetings take place regularly and these are minuted. The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 2 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? NO 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 15(2)(b) Requirement The registered person must keep the service users plan under review. (Care plans relating to the management of pressure sores must include details about the grade, size, colour and depth of the pressure sore. The improvement or deterioration of the pressure sore must be accurately documented. The type of dressing to be used must be clearly stated.) The registered person must make arrangements for the recording, safekeeping, safe administration and disposal of medicines received in to the home (All MAR sheets must be signed by the staff administering medication to residents) Timescale for action 15/02/07 2 OP9 13(2) 15/02/07 The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Chapel House DS0000018713.V320761.R01.S.doc Version 5.2 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!