Care Home: Chalk Leys

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Annual service review Name of Service: Chalk Leys The quality rating for this care home is: The rating was made on: three star excellent service 1 0 0 3 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   Yes You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Chris Schwarz Date of this annual service review: 1 8 0 2 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service Address of service: London Road Great Missenden Bucks HP16 0BB 01494863051 01494890224 manager.chalkleys@fremantletrust.org www.fremantletrust.org The Fremantle Trust The registered provider is responsible for running the service Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Name of registered manager (if applicable): Conditions of registration: Category(ies) : old age, not falling within any other category Conditions of registration: The maximum number of service users who can be accommodated is: 40 The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age- not falling within any other category (OP) Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Chalk Leys is located in Great Missenden, next to the fire station, and is within walking distance of the village centre. There are rail and bus services nearby and a few shops, churches, pubs and other amenities close to the service. The service provides care for up to thirty seven older people in single rooms, none of which have ensuite facilities. Annual Service Review Page 2 of 7 Number of places (if applicable): Under 65 Over 65 0 36 1 0 0 3 2 0 0 9 The building is divided into four groups, each with a lounge and kitchen/diner and a shared garden. People using the service have access to doctors surgeries and other community health facilities as required. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: 1.The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. 2. Surveys returned to us by people using the service and from other people with an interest in the service. 3. Information we have about how the service has managed any complaints. 4. What the service has told us about things that have happened in the service, these are called notifications and it is a legal requirement for the service to tell us about them. 5. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. 6. Relevant information from other organisations. 7. What other people have told us about the service. What has this told us about the service? The Annual Quality Assurance Assessment was returned in good time to carry out this assessment and was completed to a reasonable standard. Various improvements to practice in the past twelve months were identified such as updating the statement of purpose and service users guide, extra staff have been allocated to work at night to meet care needs, different activities have been tried and enjoyed, the manager and one of the senior team have completed a train the trainer course on safeguarding, training on infection control has taken place and the manager has achieved National Vocational Qualification level 4. Measures to improve the service further over the course of the next twelve months were also identified. Statistical information supplied in the Annual Quality Assurance Assessment showed that equipment at the service was being maintained, such as gas appliances, fire fighting equipment, hoists, portable electrical appliances and electrical hard wiring. The manager indicated that there were written assessments for handling hazardous substances and that the service had an action plan to deliver best practice in the control and spread of infection. We were told that nutritional screening is carried out on everyone admitted to the service and that actions are taken to meet the needs of people at risk of malnutrition. Eleven of twenty nine permanent care staff had achieved National Vocational Qualification at level 2 or above. No complaints, use of restraint or safeguarding issues were reported. We have been notified of significant events affecting people using the service such as illnesses, hospital admissions, deaths and an incident of missing property which was reported to the police. Twenty five surveys were returned, thirteen from staff, two from social and health care professionals and ten from people using the service. People using the service said they had received enough information to help them decide if the home was the right place for them, before they moved in. Most said they had been given written information about the terms and conditions. People using the service said they always receive the Annual Service Review Page 4 of 7 care and support they need and that the home makes sure they get the medical care they need. They said activities are arranged which they can take part in and that they usually liked the meals provided for them. People using the service said there are staff available when they need them and that staff listen and act on what they say. They said there was someone they could speak with informally if they were not happy and they knew how to make a complaint. People using the service said the home is always/usually kept fresh and clean. Responses to what does the home do well? were: makes me feel at home, they try to do their ultimate when the occasion arises. If Ive asked for advice I usually have help, keeping me clean and most carers are good, feed us well and look after us, care for us very well, the food is very nice and if I need help day or night there is always someone around and good carers. A relative who replied on behalf of a service user said I feel the staff are always helpful and approachable. They make you feel that you can come in any day or night and they inform me of any concerns or worries they have about my mother. I feel my mums carer knows everything about her needs. And if she is unwell she picks up on this. Areas where they felt the service could improve were: listen a bit more and more entertainment to keep us occupied. Social and health care professionals said the services assessment arrangements usually/sometimes ensured that accurate information is gathered and that the right service is planned for people. They said peoples health and social care needs are usually/sometimes properly monitored, reviewed and met and that the service usually/sometimes seeks advice and acts on it to improve peoples social and health care needs. They said peoples privacy and dignity were usually/sometimes respected and that the service usually supports people to live the life they choose. They said managers and staff sometimes have the right skills and experience to support peoples social and health care needs and that the service usually responds to diverse needs such as those related to disability, gender, faith and culture. They said the service usually/sometimes responds appropriately if they or a person using the service have raised any concerns. Additional comments were end of life care is of a good standard and kind and supportive to clients and their families. Appears to be a good range of activities on offer. Areas where they felt the service could improve were: very poor level of communication, carry out instructions, implement basic preventative regimes that are recommended by nursing team e.g. skin care, pressure area care, fill in fluid charts provided, fill in blood glucose records. One person additionally commented our team have experienced examples of very poor medicine management in terms of stock control and administration. Occasional lapses in hygiene standards - dirty commodes, urine bottles, soiled pads left in full view in patients rooms. Staff who returned surveys said they are given up to date information about the needs of the people they support. They said their employer carried out checks before they started work such as uptake of references and Criminal Records Bureau checks and that their induction covered the areas they needed to know about very well. They said they receive training which is relevant to their role, helps them to understand and meet the individual needs of people, keeps them up to date with new ways of working and gives them enough knowledge about health care and medication. They said their manager regularly gives them enough support and meets with them to discuss how they are working and that they knew what to do if anyone raised any concerns. Staff said the ways in which information is shared worked well and that there were usually enough staff to meet individual needs. They said they felt they had enough support, Annual Service Review Page 5 of 7 experience and knowledge to meet the different needs of people who live at the service. Areas where they felt the service worked well included: good team work, happy staff, cares very well for the residents, Chalk Leys provides a safe and secure home for its elderly residents. I think the care staff are supported well by each other. All staff know all the residents and their specific needs, provides the best care for the residents we look after, liaising with families, staff training, our residents come first, Chalk Leys has a very homely atmosphere. Residents who come to live here are made to feel very welcome, safe and secure. They are quickly integrated into a very caring environment, there is good, supportive team work. It feels like a home. Recently when there was a resident who was very poorly an extra member of the night team worked, which ensured all residents needs were met and makes sure new residents are made welcome and cared for. Areas where staff felt the service could improve were renovating the whole building as its an old building, heating system always playing up, retain staff by paying staff better, have more time to spend with residents and more training. The information that has been provided in order to carry out this review indicates that the service continues to provide a good standard of care in most areas although there are some concerns about how health and personal care may be managed. What are we going to do as a result of this annual service review? We will carry out a random inspection to look at health and personal care. This will determine whether we need to bring forward the next key inspection, which is scheduled to be carried out before 9 March 2011. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a copy of the findings in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. 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