Inspection on 28/02/06 for The Chapel House

This inspection was carried out on 28th February 2006.

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 17/01/07

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 Denis Coffey Unannounced Inspection 28th February 2006 09:00 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 The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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.V263954.R01.S.doc Version 5.0 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.V263954.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 4th October 2005 2. 3. 4. 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.V263954.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of 4 hours and included a tour of the home as well as an inspection of care records, staff files and the home’s general records. The inspector spoke with four residents and three members of staff. One requirement was made at the inspection and this was in relation to the safe keeping of medicines. What the service does well: What has improved since the last inspection? What they could do better: The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 6 The storage of medicines could be improved to ensure that these are stored safely, and cannot be accessed by people not authorised to dispense and administer medicines. 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 Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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.V263954.R01.S.doc Version 5.0 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): 2&3 Information is available for residents to enable them to know that their needs can be met. EVIDENCE: Residents accommodated at the home are provided with a written statement of terms that identifies the weekly fee payable and what this covers, the room to be occupied, periods of notice for termination of the agreement by both parties, and what extras are charged for. The statement also identifies that the first six weeks of accommodation is on a trial basis. A suitably qualified nurse assesses people prior to them taking up residency at the home, and records were seen of these being completed. The assessment addresses the person’s previous medical and psychiatric history, dietary needs, personal hygiene, continence, and an assessment of various risk factors, e.g. wandering and aggression. A new resident was taking up residency at the home at the time of the inspection and had been accompanied by nursing staff from the hospital from where they had been. It had been arranged for the The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 9 hospital nursing staff to spend time at the home on a daily basis for the first week to discuss and share their experiences and knowledge of the resident. The Chapel house does not provide intermediate care therefore Standard 6 does not apply. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&9 The care needs of the residents are identified in their individual care records, that accurately reflect the care required when there has been a change in the residents condition. The storage of medicines needs to be improved to ensure that this is done in a safe manner. EVIDENCE: The care records of three residents were reviewed at this inspection. These contained a range of appropriate plans of care detailing the needs/problems of the residents along with an objective to be achieved with interventions as to how these were to be arrived at. The plans were evaluated regularly, and when read were found to be informative reflecting the health and condition of the residents. Upon arrival at the home the inspector observed the medicines trolley to be open and left unattended in the main entrance hallway. There were blister packs of medicines on top of the trolley, and medicines were seen in a plastic cup on a trolley alongside the medicines trolley. When informed of this, the manager spoke with the nurse responsible for medicines at this time. The The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 11 manager said that the nurse informed her that she had temporarily left the medicine trolley to open the front door to the inspector, and that the medicines in the plastic cup had been dispensed by her just prior to her opening the door. The need to ensure the safe keeping of medicines was discussed with the manager, and that the nurse should have either asked someone else to open the front door, or that the nurse should have locked the medicines away in the trolley before opening the door herself. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The standard food provided was varied, providing residents with a nutritious diet. EVIDENCE: The daily menus were on display in the lounge, and they appeared varied and nutritious. Lunch on the day of inspection was a choice between ham and mushroom flan or meat type pie made from Soya, both of which were served with mashed potatoes and baked beans. The cook said that further alternatives are always available to the menu, e.g. omelettes or baked potatoes with a variety of fillings. Pancakes were served for dessert. The evening meal was to be assorted sandwiches and a selection of cakes. Residents spoken to said that they were happy with the food provided. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Information is provided for residents and visitors on how to make their concerns known, and training is provided for the staff in protecting residents’ from abuse. EVIDENCE: There have been no recorded complaints received at the home within the past twelve months. A copy of the home’s complaints procedure was on display that meets the standard required. The deputy home manager provides training in the protection of vulnerable adults that illustrates how abuse can be manifested; the symptoms that may be shown when abuse is being practiced, and the action staff should take if they suspect abuse is occurring. The home has a policy on safeguarding people, and a whistle blowing policy advising staff on how they can make their concerns known. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 24 & 26 The home provides a comfortable and clean environment for the residents to live in. EVIDENCE: The home has adequate communal facilities for the number of residents accommodated. Five of the bedrooms on the first floor and one of the corridors have been recarpeted since the last inspection. The residents’ bedrooms were comfortably furnished and had been personalised by the residents or members of their families. A maintenance person is employed for thirty hours a week at the home for carrying out general repairs and transporting laundry. Most areas of the home were visited at this inspection and were found to be clean, tidy and free from unpleasant smells. A requirement was made at the last inspection for adequate sluicing facilities to be provided and the home manager showed the inspector verification that an appropriate sluicing machine had been ordered. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 15 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): 27, 28, 29 & 30 Training is provided for the staff to equip them with the skills required for the care of the residents. Recruitment procedures are good ensuring that all relevant information is obtained on prospective staff to ensure that residents are protected from any possible harm. EVIDENCE: The home employs a team of trained nurses and care staff for the delivery of care to the residents. An additional care assistant has been rostered to work between the hours of 6pm and 10pm on a trial basis. Staff spoken with said that they are encouraged to undertake NVQ level 2 training, and to follow this up by doing an NVQ level 3. They also confirmed that they receive training in fire safety, safe moving and handling procedures, and first aid. The home is an accredited learning environment through John Moore’s University for the placement of student nurses’. The placements are for a three-week period. Three of the trained nursing staff employed at the home are undertaking a degree in gerontology at the University College of Chester. The personnel files of two staff were examined. Both of these contained a completed application form, a health declaration, a statement of terms and conditions, a satisfactory Criminal Records Bureau check, and two satisfactory references. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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): 33, 35 & 38 The health and safety of the residents and staff is well promoted. EVIDENCE: Residents’ meetings are held monthly, and minutes from the meeting of 25th January 2006 were on display. Topics discussed at this included catering, food preferences, and what the money raised from the Christmas raffle should be spent on. The personal allowances for four of the residents are paid directly to the home by Social Services, and small amounts of money are left for other residents’ by their families for the purchasing of personal items. All money paid into the home is held in a central bank account, and an individual record is made of all purchases and money paid in, with receipts kept for all transactions. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 17 Nine of the staff have undertaken food hygiene training since November 2005, and fifteen staff received fire safety training in February 2006. Twenty-two of the staff have recently completed a fire drill risk assessment. The home manager said that the fire brigade had agreed that this was an acceptable alternative to holding actual fire drills as these could distress the residents’. Records were seen of the fire alarm and emergency lighting systems being tested on a regular basis. The home manager is an accredited moving and handling trainer, and has identified that all staff will have received this training by the end of April 2006. The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 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 X X 3 X 3 X X 3 The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13 Requirement The registered person must ensure that all medicines kept at the home are stored securely. Timescale for action 14/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 The Chapel House DS0000018713.V263954.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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