Care Home: Chelsham Lodge

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What the care home does well The home provides clear and accessible information about the service it provides for potential service users and their representatives. Service users are seen as individuals and the home is run with a person centred approach. Service users are involved in a range of activities that are geared to meet their personal interests and goals and new activities are being introduced. Staff receive core training and updates and are competent in their roles. Staff are interested in the lives of the people they support and are aware of their individual communication methods and preferences for day to day support. The home is well managed and changes over the past year have improved service users` quality of life. The environment is clean and comfortable and well maintained. What has improved since the last inspection? All the requirements and recommendations made at the last inspection were found to have been met. The manager has been in post for nearly a year and has become registered with the Commission. The presence of a manager following a period when the home was without consistent management has led to positive changes. The manager and staff have worked hard to make the home more person centred and to concentrate on establishing the needs, preferences and goals of service users and offering them opportunities to try out new opportunities and experiences. This has led to a decrease in behaviour that challenges and an improved lifestyle for service users. The staff team is more stable and there has been some recruitment, further recruitment is underway. Deputy and Senior posts have been created to allow for career progression. The Statement of Purpose and Service Users Guide have been brought up to date and the complaints procedure has been made more accessible for service users. Care plans are more up to date and information in them is clear. Goals and aspirations are now being recorded and plans are more person centred. Some environmental improvements have been made and a vegetable patch has been established in the garden. CARE HOME ADULTS 18-65 Chelsham Lodge High Lane 634 Limpsfield Road Warlingham Surrey CR6 9DQ Lead Inspector Debbie Sullivan Unannounced Inspection 29th September 2008 09:05 Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 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 Chelsham Lodge DS0000013595.V372204.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 Adults 18-65. 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. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelsham Lodge Address High Lane 634 Limpsfield Road Warlingham Surrey CR6 9DQ 01883 622168 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) chelsham.lodge@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Ltd Mr Keshorsingh Beegun Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Male Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 3rd October 2007 Brief Description of the Service: Chelsham Lodge is a care home providing personal care for six adults with severe learning disabilities. Currently all individuals living at the service are male. The building is a spacious, detached two storey house situated in a semi-rural location; there is a large well kept and secluded garden. Car parking facilities are available and the home has a wheelchair accessible vehicle. All bedrooms are single occupancy and are on the ground and first floor, accessible by stairs only. Toilet and bathing facilities are within close proximity of all bedrooms. Communal facilities are on the ground floor, comprising of a spacious lounge, an activities/sensory room, a separate dining room, fitted kitchen and utility room. Warlingham village is within easy walking distance of the home. Larger shopping facilities and a wide range of leisure amenities are accessible. The home is close to the Kent and Surrey border and within travelling distance of countryside, parkland and the coast. The current weekly fee range is £3,093.48 to £1,910.34. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over six hours hours. During the visit time was spent with service users, the registered manager, deputy manager and care staff. A tour of the property took place and a range of documents including care plans, medication records, staff files and health and safety records were read. Information provided in the AQAA (Annual Quality Assurance Assessment) document completed by the registered manager also provided evidence that was used as part of the inspection process. All the requirements and recommendations made at the previous key inspection had been met and other improvements had been made to the service. The quality rating for this service is 2 star. This means that people who use the service experience good quality outcomes. What the service does well: What has improved since the last inspection? Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 6 All the requirements and recommendations made at the last inspection were found to have been met. The manager has been in post for nearly a year and has become registered with the Commission. The presence of a manager following a period when the home was without consistent management has led to positive changes. The manager and staff have worked hard to make the home more person centred and to concentrate on establishing the needs, preferences and goals of service users and offering them opportunities to try out new opportunities and experiences. This has led to a decrease in behaviour that challenges and an improved lifestyle for service users. The staff team is more stable and there has been some recruitment, further recruitment is underway. Deputy and Senior posts have been created to allow for career progression. The Statement of Purpose and Service Users Guide have been brought up to date and the complaints procedure has been made more accessible for service users. Care plans are more up to date and information in them is clear. Goals and aspirations are now being recorded and plans are more person centred. Some environmental improvements have been made and a vegetable patch has been established in the garden. What they could do better: Contracts need to be presented in a format that is more accessible for service users and they need to be signed by service users or their representative. The service users or their representatives must sign care plans. Work needed to maintain the environment and ongoing wear and tear to the home especially in shared areas needs to be completed so that the environment is kept at an acceptable standard. The repairs needed to one upstairs and the downstairs bathroom must be completed so that these areas are safe and hygienic for use. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 7 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. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the home is available to potential service users and their representatives and is accessible for service users. The needs of any prospective service users would be fully assessed and a place only offered if they could be met. Individual contracts and care plans are in place which need to be made more accessible for service users and signed by their representatives. EVIDENCE: The service users currently living at the home are all well established having lived there for approximately eight years, the service users are all male. There were no changes planned to the service user group and the home was able to demonstrate that it was meeting their individual needs. The home has an admissions policy and procedure and although no recent assessments had been undertaken information provided in the AQAA states Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 10 that any potential service user would be fully assessed and introduced to the home during a transition period. The statement of purpose and service users guide have both been brought up to date and each service user has their own pictorial copy of the service users guide with their photo on the front, the guides are in ring binders for easy access and include other photos such as of their keyworker and the house and vehicle. Each service user has a contract in place; the contracts were signed by the keyworker and registered manager although had not been signed by service users or their representatives such as relatives or care managers. The AQAA says that it is planned that contracts are made more person centred and accessible. The home demonstrated during the visit that it was meeting the assessed needs of service users. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each service has a care plan that reflects their individual support needs, goals and prefences. Care plans are up to date and maintained to a high standard. Service users are provided with opportunities to make decisions about their lives and the home and to take part in the day to day running of the service. Risks are fully assessed and risk assessments put into place. EVIDENCE: Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 12 Each service user has a person centred care plan that is accessible to them and parts of it are presented in pictures such as the personal planning book, circle of support document and activity plans. Work is in process on developing the personal planning books with service users. The home has implemented a Person Active Support approach meaning that service users are supported to experience new activities and opportunities, they are encouraged to be as involved as possible in the running of the home and are supported to take risks. The progress of service users experiencing new opportunities is recorded in writing and photos and is reviewed. Care plans are regularly reviewed internally and the three sampled showed that full reviews take place with care managers and if possible relatives. Recorded key worker meetings are held monthly. The use of a large amount of pictorial information around the home and in documentation promotes service user inclusion in the home and in decisions about their own lives. Care plans also have health action plans, cultural needs assessments, and information on personal preferences such as how service users like to receive personal care and take their meals. The information is kept confidential and the plans are available to service users at any time. Care plans show that service users are given support to make decisions about their lives and discussion with staff, the manager and observation during the visit evidenced that service user empowerment is a core value of the home. Service users were benefiting from having opportunities to make more choices and take part in more activities such as starting to go to the bank to take out their money, choose meals and some cases have more contact with relatives. All new activities where there could be risks attached are thoroughly risk assessed. Staff were very familiar with the individual communication styles of service users and the meaning of gestures and moods, communication methods are included in care plans. Staff were observed via knowledge of service users wishes to plan the activities and pace of the day. Participation in the day to day running of the home has increased, service users participate to the extent they wish with an appropriate amount of support. There is a weekly menu discussion meeting, service users are welcome to join in staff meetings and the organisation is promoting service user involvement in recruitment. Approaches have been made for the provision of advocates although there is a waiting list for them; the manager gave an example of an advocate being made available to support a service user to attend a specific appointment on a one off basis and was hoping that more availability would become possible. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to take part in a wide range of activities at home and in the community. New activities are offered and individual interests and skills built upon. The home works hard to maintain contact with relatives at a level that suits the relatives and service user. Meals are healthy and varied and menus are chosen by service users on a weekly basis. EVIDENCE: Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 14 Service users have opportunities to take part in a wide range of activities and the scope of activities available to them has been increased since the last inspection. Each service user has a new activities planner that includes colour pictures; a staff member said they are making a more personalised planner that will include pictures of the service user doing the activities. The range of opportunities in the community includes swimming, attending local day centres, a drop in club, bingo, going out for meals and to places of interest and visiting local parks. The home had recently sourced horseriding for one person and the service user was also going to buy a bicycle. Hydrotherapy was being sought for another service user. Service users are enjoying taking part in some activities for the first time such shopping in the nearby supermarket, going out for a haircut and going to the bank, they are offered new activities and can choose to take them up or try them out. The use of the facilities in the local community was being expanded and opportunity sessions had been started to introduce service users to activities that they may not have tried out before, their interest and enjoyment in participating was well documented and included photos and if they liked the activity it was built on. During the visit service users were engaged in a variety of activities one person went out for a walk and a picnic with a staff member, another attended a day service and another went out later. At home service users are supported and encouraged to take responsibility for keeping their rooms clean and tidy and to help with other domestic tasks and in the kitchen. One service user enjoys hoovering and was doing this and there is free use of the kitchen to make drinks and snacks independently or with the help of staff. The garden is large and well kept; a service user who uses a wheelchair outside the house was having a walk round the garden with a support worker before smoking outside. A small vegetable patch has been established this year in the garden and has produced fruit and vegetables such as tomatoes and strawberries, its progress had been recorded in photos and service users had been fully involved in the work and other gardening tasks. The manager hopes to extend the growing area next year. Plans were being made for holidays for service users, each has an individually tailored holiday of their choice with staff, a key worker had booked a Centre Park holiday on the day of the inspection and was looking forward to taking the service user who had been there last year and enjoyed it. The home is very pro active in supporting contact with relatives, all the service users have family contact to some extent, one regularly spends a night away with a relative, contact with another relative has been nurtured and increased as the relative has a good relationship with the keyworker and another service user has been reunited with their brother having been separated for 47 years. Work to trace the brother had been undertaken by the manager and staff over the past year and a meeting between them at the home arranged, again this is documented in photos, the brother keeps in regular contact. Keyworkers or the Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 15 manager contact some relatives at least monthly by phone and records of the matters discussed are on file. Cultural and spiritual needs are documented and a service user is supported to practice their religion. During the visit service users moved freely about the home and routines were in place but flexible and staff spent time with service users who liked to be in company but respected when they wished to spend time alone. Service users choose the menu for the week at Sunday menu meetings, a four week menu is no longer used and the menu changes each week. Then menu for the current week was healthy and varied. The main meal is taken in the evening with a light lunch. On the day of the visit service users were able to choose when to have their meal and where to eat, lunch was soup and sandwiches and those needing assistance with their meals were being supported sensitively by staff. One service user had been supported to maintain a healthy weight with a healthy eating plan. The home respects the diet followed by a service user due their culture and foods they cannot eat are documented. Bulk food shopping is no longer done as there is a supermarket very nearby and service users have started shopping there so ingredients are freshly bought several times a week. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The personal care needs of service users are provided in the way that they prefer and their privacy and dignity is respected. Healthcare needs are well met and the well being of service users has improved with overall improvements to their lifestyle. The medication policies and procedures in place protect service users and are robust. EVIDENCE: Each service user has a health action plan drawn up as part of their personal care plan and preferences for the delivery of personal care are recorded. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 17 Some service users at the home are very independent as regards their personal care and hygiene whilst others need more support. The needs of each service user are complex and staff demonstrated a thorough understanding of each persons needs, abilities and likes and dislikes. Routines are flexible as far as possible and at the start of the visit some service users were up and dressed, with others practising their personal daily routines in the timescale they were used to. Due to the needs of the service user group some people have set routines that it would be distressing for them to veer from and the home fully respects this. Care and health action plans include information about appointments attended and health needs as well as correspondence to and from health professionals. Service users are supported to maintain contact with a range of healthcare professionals such as dieticians, a chiropodist, a psychiatrist, aromatherapist and the GP. It has a good relationship with the GP who visits each week. The manager said that it is hoped that the amount of medication service users are taking can be reduced under very careful supervision by the psychiatrist. Healthy living is promoted and where there could be risks to health, such as through smoking, the GP is consulted whilst the rights of service users to smoke if they wish is respected. One service user was experiencing some problems due to arthritis and careful negotiations were taking place with the orthopaedic surgeon, local authority and family regarding the possibility of surgery. Medication is safely and securely stored and medication recording was in order. The home had been visited by its pharmacy this year and the resulting report recorded that the administration, recording and documentation regarding medication were excellent. Medication reviews are held six monthly. PRN protocols are in place and there had been a reduction in the use of PRN medication due to an overall improvement in the lifestyle of service users. With the introduction of more occupation and activities and the person centred approach, incidents of self-harm or aggression towards others or property is decreased. The use of PRNs is closely monitored and checked by the manager. The manager had recently written to relatives requesting they provide information on the wishes of families and service users in the event of death. One response from a relative was seen on a care plan. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is accessible for service users and made available to others. Systems are in place to protect service users from harm and staff are aware of what constitutes abuse. EVIDENCE: The complaints procedure has been reviewed since the last inspection, it is available in a pictorial and audio format. There had been no complaints made since the last inspection and the Commission had not received any complaints, concerns or safeguarding alerts in relation to the service. Service users have varying degrees of verbal communication, staff understand their methods of communication and would be aware if they were distressed or unhappy about anything. Service users would need the support of a care manager, staff member, relative or advocate to make a formal complaint. Discussion with the manager and staff made it clear that staff are attuned to the mood of service users. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 19 The home has a safeguarding vulnerable adults porocedure, staff receive POVA training and a staff member spoken with said that they would feel confident in raising any concerns about suspected abuse. Recruitment procedures are thorough and the required checks are undertaken. Service users who could present challenging behaviour have become more settled due to the increase in activities and choices offered to them and the manager said that incidents of challenging behaviour are greatly decreased, should they occur guidelines are in place for staff to follow to ensure that other service users and staff are kept safe. Service users are supported with the management of their finances, transactions are recorded and there is regular auditing of accounts. A new development is that supported service users who wish to are being supported to collect their money from the bank. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a clean, comfortable and homely environment. Their bedrooms are personalised and meet individual needs. Staff work hard to maintain a homely feel whilst general maintenance must be kept up so that the standard of the environment is maintained and the home kept safe for service users. EVIDENCE: Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 21 The home is well decorated, clean, comfortable and homely. It is spacious with plenty of room for service users to spend time alone away from their bedrooms as well as to be with others. Shared areas are the large light and airy lounge, the dining room leading onto the kitchen, a room with sensory equipment and a quiet room upstairs. The garden is well kept, large and secluded and is accessible with a path around it and there is a patio area with chairs and tables. All the bedrooms are of a good size and decorated to a high standard in different colour schemes, they have wash handbasins. Bedrooms were personalised to varying degrees depending on the wishes of the service user with items such as pictures ornaments and photos, the manager said it was hoped some more personal items could be added although some service users prefer the minimum of items and rooms to be unchanged. There are two upstairs bathrooms and one downstairs; one downstairs bathroom had cracked tiles at on the surround at the back of the bath that needed attention. The home was cleaned to a good standard although some areas of the skirting in the dining room needed more thorough cleaning and due the nature of the service user group daily wear and tear of décor and furniture especially downstairs is ongoing. The manager said he was awaiting maintenance work on the minor repairs and had also identified pieces of furniture that needed replacing, sometimes this had to be done very sensitively as some service users find environmental changes difficult. The laundry was clean and hygienic and is accessible to service users who do their own laundry either independently or with the support they need. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A staff team that is well trained and supported meets the needs of service users. The number of staff who have gained an NVQ in care needs to be increased. Recruitment procedures are thorough and protect service users. EVIDENCE: During the visit there were enough staff on duty to meet the needs of service users, four support staff including the senior as well as the deputy manager were on duty in the morning with four staff on duty in the afternoon, at night there are two waking care staff. There was a mix of male and female staff from different cultural backgrounds, some had worked at the home for a number of years, one had returned there having worked at the home before and one staff Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 23 member spoken with had started early in the year. The staff group has become more stable and a staff member said they work well as a team. Staff observed were service user focussed and spent time taking service users out, communicating and interacting with them, observing moods and activities and making sure they were safe. Staff interactions with service users were supportive and sensitive and service users were comfortable with them. Staff spoken with and observed were genuinely interested in the lives of service users and were positive about having opportunities to enable them to try out new experiences and improve their lifestyle and very keen to give information on the outcomes. The organisation has a thorough recruitment procedure and the registered manager is an organisational recruitment coordinator. Recruitment records are held at head office with a recruitment checklist being kept in the home with necessary information, the checklists for three staff members were read, all stated that staff had had an up to date CRB check prior to starting at the home, references had been received and employment histories checked. Part of the organisations business plan is to involve more service users in recruitment. Staff receive induction and core training and POVA training is regularly updated. Service specific training such as epilepsy and autism are provided and staff spoken with were impressed with training offered. Comments included The thing I like about this organisation is there is lots of training and The home is excellent with training. Staff also have equality and diversity and Person Active Support Training (PCAS) which focuses on the promotion of service user needs and choices. There have been some staff changes since the last inspection and whilst the number of staff currently employed with an NVQ at level 2 or three in care has increased slightly it remains less that 50 of the staff group and needs to increase further. There were two vacancies at the time of the visit and recruitment was underway. Regular team meetings are held and staff are have one to one recorded supervision monthly, the deputy and senior share supervision with the manager. Staff spoken with said they felt well supported, one said they were 100 supported . Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users and has a friendly and open feeling. Internal quality review systems are in place and results are well recorded. Safe working practices are observed to ensure the safety of service users and staff. EVIDENCE: Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 25 At the time of the last key inspection the manager was newly in post, the manager has now become registered with the Commission and is experienced and well qualified for the role. The Deputy and senior support worker complement the managers role and the service manager for the home supports the manager. The service had been through a period of instability due to inconsistent management within the home, it is now more settled and positive changes reflect this. There have been improvements since the last inspection that are reflected in this report, these include better record keeping and care plans, a more cohesive staff group and more occupation and activity for service users. The views of service users are sought at keyworker meetings and house meetings and stakeholder surveys are sent out annually. The home is run in the best interests of service users and has a friendly and inclusive feeling. The service manager undertakes Regulation 26 visits monthly; reports are detailed and identify areas where action is needed. The organisation also conducts an annual healthy lifestyle audit and quarterly internal quality reviews. A current Avenues newsletter was seen that had an article referring to improvements in the home and that it had won a related award. Policies and procedures are in place that are revised as necessary and are available to staff. Health and safety records are kept and safe working practices are observed. Records are held confidentially and service users have access to their care plans. The service has plans for further development and is consolidating work done during the past year. The home has a fire procedure and fire practices take place several times a year, the record of the most recent recorded a successful evacuation in which all service users were involved. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 3 X 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 3 3 Version 5.2 Page 27 Chelsham Lodge DS0000013595.V372204.R01.S.doc 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 YA5 Regulation 5(C) Requirement The registered person shall produce a standard form of contract for the provision of services and facilities by the registered provider to service users In that contracts must be made more accessible for service users and signed by them or their representative. 2. YA6 15(1) Unless it is impracticable to 30/11/08 carry out such consultation the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs are to be met. In that service users or their representatives must sign and agree their care plan. 3. YA42 13(3)(a)(b)(c) The registered person ensures so far as is reasonably practicable the 10/11/08 Timescale for action 31/12/08 Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 28 health, safety and welfare of service users and staff In that the cracked tiling on the surround of the downstairs bathroom must be replaced and poorly fitting pipework covering in the upstairs bathroom be replaced. 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. Refer to Standard YA30 Good Practice Recommendations It is recommended that the dining room skirting boards be cleaned thoroughly on a regular basis. Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Chelsham Lodge DS0000013595.V372204.R01.S.doc Version 5.2 Page 30 - 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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