Inspection on 04/10/05 for The Chapel House

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 28/02/06

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 4th October 2005 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.V253748.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.V253748.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.V253748.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 16th February 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.V253748.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 6 hours and included a tour of the home as well as inspection of care records, staff files, and the home’s general records. The inspector spoke with five of the residents, and four members of staff. What the service does well: What has improved since the last inspection? What they could do better: The present sluicing facilities are not adequate for the disinfection of equipment and should therefore be replaced with a satisfactory facility that will prevent the risk of cross infection. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 6 All of the personnel staff records and records of the residents finances should be kept in the home. The provision of fire safety training for the staff from an approved instructor would improve the staffs’ knowledge and competence in reducing the risk of fire, and their ability to respond should a fire occur at the home. 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.V253748.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.V253748.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): 1&3 Residents are assessed and given information to make sure that they know their needs can be met at the home and what their rights and responsibilities are whilst living there. EVIDENCE: The home has a statement of purpose that meets the standard required. This along with a copy of the last inspection report was on display in one of the lounges. The care records of two people recently entering the home contained pre-admission assessments that had been carried out by the home manager. Needs/problems identified at the time of assessment had been addressed in the residents’ care records. The Chapel House does not provide intermediate care therefore Standard 6 does not apply. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Care planning and monitoring means that residents’ social and healthcare needs are met by the staff at the home. Staff ensure that residents’ dignity and privacy is respected and the medicines are well managed so that residents receive their correct medication. EVIDENCE: The care records of three residents were examined at this inspection. All of these contained an assessment of ability based on the activities of daily living, plans for their identified needs, appropriate risk assessments, and daily records reporting on their health and welfare that were informative. All of the residents are registered with a general practitioner and have access to the NHS facilities. Records were seen of other healthcare professionals being involved in the care of residents, e.g. opticians, dentists and chiropodists. Appropriate equipment was provided for residents who have been identified as being at risk of developing a pressure sore. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 10 An examination of the residents’ Medicine Administration Record sheets showed that these had been filled in correctly. During the course of this inspection one of the trained nurses was observed administering medicines to the residents in a calm, friendly and safe manner. A random sample of medicines was chosen for stock reconciliation and was found to be correct. Staff were observed to interact with residents in a friendly and supportive manner and to address them appropriately. They were also observed to maintain the dignity and privacy of the residents when attending to their personal care. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 & 15 Activities are provided for residents to take part in to keep them active and stimulated. The standard of food provided at the home is satisfactory, providing residents’ with a well balanced and nutritious diet. EVIDENCE: One of the care staff employed at the home has a specific role for three afternoons a week to organise social and recreational activities for the residents, e.g. nail care, hand massages, reminiscence and sing-a-longs. Care staff are also involved in the provision of social activities at other times in the week, and participate in such activities as passive exercises and reading newspapers with the residents. Outside entertainers are booked every three months and a mobile library visits the home on a monthly basis. The home has an open visiting policy, but visitors are requested not to visit at meal times. Ministers from the local churches visit the home regularly to hold communion services and to see residents individually if they so wish. Lunch on the day of inspection was sausages, mashed potatoes and baked beans followed by apple crumble and ice cream. The evening meal was to be a selection of sandwiches, soup and cake or yoghurt for dessert. Alternatives to the main courses are available. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 12 The Chapel House DS0000018713.V253748.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 There is information available to guide residents and relatives on how to make a complaint and who to make it to. There are procedures and guidance available for staff to ensure that residents are protected from abuse, harm and poor practice. EVIDENCE: There have been no recorded complaints received at the home since the last inspection. The home has a complaints procedure that meets the standard required that was on display in one of the lounges. The home has a whistle blowing policy that advises staff on how to make their concerns known about poor practices, and assures staff that they can do so without the fear of reprisals. The deputy manager is responsible for the provision of adult protection training to the staff. This training identifies the types of abuse that may occur and the procedure for reporting suspected or observed abusive practices. The Chapel House DS0000018713.V253748.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, 20, 21 & 26 The home provides comfortable and safe spaces for the residents to live in. adequate bathing and toilet facilities are provided, but sluicing facilities require improving to reduce the risk of cross infection occurring. EVIDENCE: The standards of décor and furnishings have been well maintained. The hallway on the third floor and the corridors and lounges on the ground floor have been redecorated since the last inspection. A decoration programme for October/November has been drawn up for the redecoration of all the ground floor bathrooms, and the corridors and bedrooms on the first floor. The home provides three lounges and two conservatories (dining areas) for use by the residents, and plans have been made to convert an office on the first floor into a small lounge. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 15 There are a total of five communal baths and ten toilets at the home, with seven bedrooms equipped with ensuite toilets. A new shower room was in the process of being installed at the time of inspection. All parts of the home were visited at this inspection and found to be clean, tidy and free from unpleasant smells. The home has its own laundry facilities of four washing machines; four tumble dryers, and ironing equipment. Upon completion of laundering the residents clothing is returned to their bedrooms and put away. The temperature of frozen and chilled food products are recorded upon delivery, and a similar record is maintained of the cooked meats prior to these being served to the residents. The home’s sluicing facilities comprise of open sluicing sinks (that are supplied with a hot and cold water supply) where the commode pots are washed after use. This facility is not adequate to disinfect commode pots that may be infected. See Requirement 1 The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 There are enough staff rostered to be on duty to meet the needs of the residents. Recruitment procedures are followed well ensuring that residents the protection of residents. EVIDENCE: A review of the staffing rotas showed that there are two trained nurses and six care assistants on duty in the morning and one trained nurse and five care assistants in the afternoon, and one trained nurse and three care assistants during the night. The home also employs a team of domestic, catering, maintenance and laundry staff. All of the care staff have been offered training leading to an NVQ level 2 in care. The deputy manager who was in charge of the home on the day of inspection was aware of the need for 50 of care staff to have attained such a qualification by the end of 2005. The home is an accredited training placement for students undertaking nurse training, and the manager and deputy have received training in mentoring and assessing these students whilst on placement at the home. The deputy manager is currently undertaking a degree course in gerontology. The personnel records of two staff were examined at this inspection. The required information was seen in both of these with the exception of one, where only one reference had been obtained for one of these staff. The deputy manager said that a second reference had been applied for and that this person was currently undertaking induction training and would not be providing personal care to the residents until this reference had been obtained. The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 17 The staff records were being stored in a home owned by the same proprietors that is located within close proximity to The Chapel House. These records must be kept within the registered premises. Staff training records showed that they have received training in the safe moving and handling of residents, a five-day First Aid training course (5 staff), and a one-day First Aid training course (3 staff), and adult protection. Catering staff have received food hygiene training. See Requirement 2 See Requirement 3 The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The home is well managed and residents’ views are taken into account so they have an influence in how the home is run. The practices in the home ensure that that residents are safe and their welfare is promoted, except for the provision of satisfactory fire safety training for the staff. EVIDENCE: The registered manager has recently commenced maternity leave, and the deputy manager who has attained an NVQ level 4 in management and care has assumed the responsibility of managing the home in the absence of the home manager. A satisfaction survey questionnaire was sent out to the families of the residents in June this year, thirty of which have been returned. This questionnaire addressed such issues as care, staff attitudes, food and accommodation. The The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 19 deputy manager was in the process of collating the information received. One action taken from the responses has been to write to the families offering to carry out a care review of their relative with them. Five of the residents have their weekly personal allowances paid directly to the home by social services. Records were maintained of money received, and expenditure made on behalf of these residents. The families of other residents are invoiced for services not covered in the weekly fee, e.g. hairdressing and chiropody. Records relating to the residents’ finances were being kept in the home next door to The Chapel House. These records must be kept within the registered premises. Records were seen of the fire alarm system being tested on a weekly basis, and the emergency lighting, monthly. A fire risk assessment on the home had been completed, but there was no record of the staff having received fire safety training this year from an approved instructor. The deputy manager has shown a fire safety video to the staff and has devised a questionnaire for them to complete once having viewed this video. This arrangement do not meet the standard required. An examination of the residents’ accident records showed that between 1st July 2005 and 30th September 2005 there had been ninety-eight accidents recorded, the majority of which were attributed to falls/trips. These accidents are audited monthly detailing the time of the accident, description of any injury sustained and how the accident occurred. Risk assessments were in place for the safe use of bed rails where these had been fitted to a resident’s bed. Following a recent event where one of the residents was able to leave the home unobserved, numbered security key locks have been fitted to all of the external doors around the home. See Requirement 4 See Requirement 5 The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 20 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 3 X 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 3 3 X X X X 2 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 3 X X X 2 X X 2 The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 21 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 OP26 Regulation 13 & 23 Timescale for action The provision of adequate 31/12/05 sluicing facilities is required to prevent the spread of infection in the home. Two satisfactory references must 20/11/05 be obtained prior to staff commencing employment at the home. The records of all people 20/11/05 employed at the home must be kept at the home. A record of all money or 20/11/05 valuables deposited for a resident’s safekeeping or received on a resident’s behalf must be kept in the home. Arrangements must be made for 30/11/05 all staff to receive suitable training in fire prevention, and for such training to be maintained. Requirement 2 OP29 19 3 4 OP29 OP35 17 17 5 OP38 23 The Chapel House DS0000018713.V253748.R01.S.doc Version 5.0 Page 22 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.V253748.R01.S.doc Version 5.0 Page 23 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.V253748.R01.S.doc Version 5.0 Page 24 - 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!