Inspection on 25/10/05 for 45 Jubilee Road (Chartwell House)

This inspection was carried out on 25th 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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

45 Jubilee Road (Chartwell House) 14/07/06

45 Jubilee Road (Chartwell House) 23/05/05

45 Jubilee Road (Chartwell House) 29/09/04

45 Jubilee Road (Chartwell House) 27/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 45 Jubilee Road (Chartwell House) Waterlooville Hampshire PO7 7RE Lead Inspector Mrs Pat Hibberd Unannounced Inspection 25th October 2005 08:00 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 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 45 Jubilee Road (Chartwell House) DS0000011746.V260269.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 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. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 45 Jubilee Road (Chartwell House) Address Waterlooville Hampshire PO7 7RE 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) 023 9243 3699 Mr David Rodgers Mrs Anita Denise Rodgers Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD are only to be accommodated between the ages of 30 to 65 years 23rd May 2005 Date of last inspection Brief Description of the Service: 45 Jubilee Road is a privately owned service for three people who have a learning disability . The owners are David and Anita Rodgers. Since the last inspection the owner Mr David Rodgers has informed the commission that Mrs Anita Rodgers no longer manages the Home. A new manager is being sought with David Rodgers overseeing the management of the Home in the interim. The Home is a three bedded bungalow with an office in the roof space. It is in a residential area of similar properties and within walking distance to local shops and leisure facilities. Twenty - four hour staffing is provided which is flexible to the needs of the Service Users . There is a vehicle available for Service Users which is unmarked. This service would not be suitable for wheelchair users as the rooms and door sizes would not be able to accommodate a wheelchair. However, due to the needs of Service Users accommodated a ramp has been installed from the lounge and kitchen doors to secure access for all to the small garden to the rear. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four and a half hours and was the second unannounced inspection of the 2005/2006 inspection programme. Fourteen of the forty three Standards relating to Younger Adults were assessed. All of the core standards have now been inspected during this inspection programme. There were a number of improvements identified at the last inspection one of which remains outstanding details of which can be found in the body of the report. During this inspection there were four requirements identified and one recommendation details of which can also be found in the main body of the report. The inspection included a tour of the Home and discussions with all residents. Two members of staff and a manager from another Home owned by David Rodgers (who represented Mr Rodgers due to him being on holiday at the time of the inspection) were also spoken to and contributed to the inspection process. Feedback forms were received from the three residents and two relatives of which further details can be found in the main body of the report. Two residents’ files were viewed and care provided by the Home in all areas of their life assessed and discussed with the manager, two members of staff and one resident. Due to the needs of another resident observations were made of staff support and interaction with the individual. What the service does well: It was evident from discussions held with two staff that they had an understanding of residents’ needs and were endeavouring to follow care plans. Residents indicated verbally or through signing / gesture that they were very happy with the care they receive and liked living at Jubilee Road. From activities organised and interests pursued by residents the Home is endeavouring to provide a stimulating and varied lifestyle. Staff training is varied and appropriate to residents’ needs. Feedback forms received from the three residents accommodated indicated that they were happy living at Jubilee Rd, felt well supported by staff and would talk to management if they were unhappy. . 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: There were a number of areas of improvement identified. The first relating to the need for all residents’ files to be up to date including care plans, medication administered reflecting records held in care plans and risk assessments dated as to when completed and reviewed. The Registered provider Mr Rodgers had agreed to review all files at the last inspection. This work has not been completed therefore a requirement was made on this occasion. Staffing is further required to be reassessed and increased in the mornings if risk assessments identify a need. A cross gender policy and procedure is required to written. COSHH (control of substances hazardous to health) sheets need to be obtained from manufacturers for all products used in the Home. These should be shared with staff. Documentation confirming that the hoist in the bathroom has been serviced needs to be available in the Home for inspection. Consultation with a health trained professional with regards to the appropriate cleansing of personal aids used by two residents needs to take place. An assessment by an appropriately trained professional needs to be undertaken of two residents accessing the bath and Home vehicle. Damp patches on the ceiling in the bathroom need to be addressed. A system needs to be put in place to monitor food temperatures and labelling of opened foodstuff in the fridge a task undertaken by members of the staff team. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 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. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 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 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed on this occasion. EVIDENCE: 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The arrangements for care planning require some improvement to ensure all residents care needs are met and, that choices they make about their daily life are within a risk management framework of care. EVIDENCE: Residents are encouraged to make decisions about their lives through menu planning, personalising their bedrooms and, identified needs in relation to how they choose to spend their day. Residents’ meetings are held three monthly although staff indicated that it can be difficult engaging all individuals in a meeting together. Regular meetings between residents and their key workers therefore, further contribute to decision making and choices. On the day of inspection the three residents were preparing to go to Day Services of which all attend five days a week. Observations of support required were made of which a number of concerns were identified and discussed with the staff member on duty in the Home and a staff member who was attending the Home to drive two residents to their Day Service. It was evident that whilst the staff member on duty was supporting two residents to prepare for their day ahead another resident was standing outside 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 11 waiting for their transport to Day Services. The staff member indicated that he had been verbally instructed by Mr Rodgers that the individual should either be supported whilst waiting for the transport or, should remain indoors as they are vulnerable and potentially at risk. However, he further indicated that he is unable to leave the other two residents and, that it was the resident’s choice to wait outside. There was no evidence of a risk assessment having been undertaken or, written guidelines to staff as to how to manage the potential risk to the resident when standing outside and out of view of staff on duty. The staff member indicated that at times a second member of staff would be helpful in the mornings to assist with individuals’ needs. Further details of which can be found in the staffing section of this report. Observations of the member of staff supporting residents to access the Home’s vehicle raised further concerns as in order to enable one resident to get into the vehicle the staff member was seen to lift the individual from the floor and into the vehicle. The staff member indicated that whilst he had undergone moving and handling training and was aware that he could be placing himself and the resident at risk this was the only way staff could get the resident into the vehicle . There was no evidence of a professional assessments having been undertaken as to how to support the resident into the vehicle or risk assessments in care plans viewed. At the last inspection care plans viewed did not indicate when risk assessments had been undertaken and whether they had been reviewed . For example information relating to medication prescribed held in one resident’s file was out of date with Mr Rodgers confirming this should have been removed. Mr Rodgers further indicated that he would need to look at all of the three residents’ files, as he was unsure as to how up to date they were. Two files were viewed during this inspection and care “tracked” with two staff and the manager representing Mr Rodgers. A discussion was held with one resident and observations of support for another residents made. It was evident that care plans and risk assessments had not been reviewed in all areas of individuals lives as indicated and agreed by Mr Rodgers at the last inspection. Whilst staff were able to demonstrate an awareness of residents’ needs documentation in files was either not available or out of date. One example being of support required for one resident when walking to the pub. The staff member on duty indicated that the resident will choose to walk in the middle of the road potentially placing themselves at risk. There was no evidence of a risk assessment having been completed providing documented guidance to staff. There were Care Management assessments available in some of the residents’ files with evidence that the local Community Health Teams were involved with individuals as necessary. Monthly reviews of residents’ needs are undertaken by key workers. However, with care plans and risk assessments held in files not having been updated it was unclear as to whether the monthly reviews reflected all of the individuals’ needs. A requirement was made for all care plans and risk assessments to be up to date and regularly reviewed with consultation and assessments requested from 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 12 professionals in relation to moving and handling issues identified and previously detailed in relation to supporting one resident into the Home’s vehicle. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 16 Residents are supported to maintain friendships and family relationships with rights and responsibilities upheld in their daily lives. EVIDENCE: Residents are supported to maintain family links and friendships with all visitors welcome to the Home with the individuals agreement. Visitors can meet with residents in their bedroom or lounge if they so choose. Monthly records completed by key workers indicated that residents have contact with relatives/friends and, that the contact is welcome by residents. The Home has a policy and procedure with regards to sexuality and relationships of which one staff member confirmed they were aware of. Daily routines in the Home enable resident’s to have choices, maintain their independence and individuality. One staff member was able to give a number of examples which included resident’s being addressed by their preferred name, personal care being offered in a respectful and dignified manner and residents having unrestricted access to all parts of the Home with the exception of other residents’ bedrooms. Observation of care provided during the inspection confirmed the 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 14 practices described with residents indicating through discussion or gesture that they felt well supported by staff and have positive relationships with staff. Residents are supported to undertake household tasks if they so wish with one file indicating that a resident enjoys helping staff in the garden. There are no pets kept by residents although this could be negotiated if all residents were supportive of having a pet in the Home. Residents do not currently smoke with staff being required to smoke outside if they wish to do so. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Although the Home’s practices to ensure the physical and health needs of residents are being met require some improvement. Resident’s receive care in a dignified, respectful and individual manner. The Home’s medication policy and procedure is not being fully implemented. EVIDENCE: Care plans viewed confirmed that residents have access to a GP, health professionals as required and are supported to attend dental appointments, chiropody, the optician and out patient appointments. There were details of personal care /support to be provided to residents in care plans although as previously detailed risk assessments are required to be updated of which further details can be found within this section of the report. Staff were observed providing care in a dignified and respectful manner with times for getting up, going to bed and mealtimes being unrestricted dependent on the day ahead. There were however, a number of requirements identified following observation and discussion with the staff member on duty. Despite there being a hoist in the bathroom to assist two residents to have a bath the staff member on duty indicated that they did not feel confident to 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 16 independently support one of the residents to use the hoist and have a bath. As a result the resident can only have a bath if there are either two staff on duty or as was advised by the manager representing Mr Rodgers a staff member on duty who felt confident to provide the support independently. The care plan/risk assessment completed by the Home was unclear indicating that “two staff should support if possible”. A requirement was made for a professionally trained person to undertake an assessment of residents’ needs which should be shared with staff and kept under review. A further issue was raised regarding the cleansing of aids used by two residents of which there was no documentation in the Home to provide specific guidance to staff. It was agreed that the manager would contact a nurse at the local surgery to discuss infection control and the most appropriate way to cleanse the aids. This will be followed up at the next inspection. Further discussions with the staff member on duty highlighted that they had discussed some concerns with management in relation to providing personal care to female residents when lone working. The Home does not have a cross gender policy and procedure and it was agreed that this should be complied and shared with all staff. The standard relating to medication records was not fully assessed on this occasion having been inspected at the last inspection. However, at the last inspection it had been agreed with Mr Rodgers that he would review all files and up date medication administered to reflect records held. It was evident from two files viewed that the care plans contained information relating to medication no longer prescribed. A requirement was made therefore to update the medication records in care plans. Two staff confirmed they had received moving and handling training, infection control training and stoma care training which is being monitored and reviewed by a district nurse. Full guidance of the stoma care were detailed in the relevant care plan with the staff member on duty indicating that they felt confident to address the needs of the individual. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed on this occasion. EVIDENCE: There have been no complaints made to the Home or the commission since the last inspection. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in a clean, well maintained, suitably furnished comfortable environment which will be further enhanced on completion of the planned decoration. Aids used in the Home must be maintained to ensure the safety of residents. EVIDENCE: The Home was clean, bright and hygienic with policies and procedures and systems in place including infection control /food hygiene and moving and handling training for staff. Staff indicated that they were aware of their responsibilities in relation to hygiene in the Home, were provided with gloves and aprons as required and had received infection control training. Hand washing facilities were seen in the kitchen and bathroom of the Home. One resident indicated that the Home environment was comfortable with suitable furnishings to meet their needs including appropriate seating in the lounge. There is not a separate dining room although a dining room table and chairs is accommodated in the lounge. All radiators are covered. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 19 The Home is located close to shops, leisure facilities and public transport although the Home has their own transport available for residents. The statutory fire officer has not inspected the Home this year. Smoke alarms are fitted as is a fire alarm system. Since the last inspection a new carpet has been fitted in the lounge and new flooring in the bathroom and kitchen. There are plans to replace the hall carpet and redecorate the area which will further enhance the improvements made. The manager representing Mr Rodgers also indicated that damp patches on the ceiling of the bathroom are to be addressed. This will be followed up at the next inspection. There is a planned maintenance and renewal programme in place for the fabric and decoration of the premises. Two residents use a wheelchair when accessing the community. The manager indicated that they are regularly serviced and were stored in the garage. One requirement was made with regards to the Home having documented evidence that the hoist in the bathroom had been serviced and was safe and suitable for its stated purpose as detailed in care plans. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 The Home has a well trained staff team although staffing must be reassessed to ensure residents’ needs are being met. EVIDENCE: The Home has a staff development and training programme with the Registered Provider, Mr Rodgers having responsibility for the budget and training programmes. The Home has a staff team of six. Three are in the process of completing NVQ ( National Vocational Qualification training). All new staff receive a thorough induction in line with TOPPS with one staff member indicating that the process had been very informative and supported by Mr Rodgers. The majority of staff have undertaken a range of training which includes: moving and handling, first aid, fire safety, food hygiene, medication administration, COSHH, infection control, stoma care, Adult Protection and health and safety. Mr David Rodgers is undertaking the Registered Manager’s Award and NVQ level 4 in care. Staff indicated that staff meetings are held on a regular basis of which they find beneficial with issues raised generally followed up by management. Staff rotas viewed indicated that there is one waking staff member on duty from 10pm until 9am throughout the week and two staff on duty between 4pm and 10pm Monday to Friday .On a Saturday and Sunday there are two 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 21 staff on duty between 9am and 10pm. Due to residents attending Day Services Monday to Friday there are no staff on duty between 9am and 4pm. A requirement was made relating to staffing. As detailed in the individual needs and choices section of this report one staff member expressed some difficulties in meeting all needs in the morning when assisting the three residents to prepare for Day Services. It was further evident from discussion with the manager representing Mr Rodgers that a contingency plan was not in place in the event of a staff member being available to support residents should they be unwell or, not wishing to attend Day Services. At present one option would be for the waking night staff member to remain on duty until alternative arrangements could be made. However, it was evident from rotas viewed and discussions held with the staff member that they would have been on duty since 4pm the previous day. The requirement made related to staffing being reviewed and increased as necessary with a contingency plan in place in the event of residents not attending Day Service. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Residents are consulted and their views considered as to the development of the Home. Some areas of health and safety require some improvement to ensure the safety of resident’s accommodated. EVIDENCE: There is currently a vacancy for the Registered Managers post with Mr David Rogers overseeing the management of the Home until a new manager is appointed. The Standard could not, therefore be fully assessed on this occasion. Two staff indicated that they felt supported by Mr Rodgers. Quality assurance systems in place were discussed with staff which include monthly reviews of residents care, yearly questionnaires circulated to residents, staff and relatives and consultation between staff and residents on a daily basis. Feedback forms received from three residents and two relatives prior to the inspection indicated that they were consulted as to care provided and were satisfied that their views were listened to and acted upon. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 23 Discussions with one resident confirmed that they felt comfortable with staff, that they were consulted as to care provided and knew who to talk to if they were unhappy. An annual development plan for the Home was seen on the kitchen wall although it was acknowledged by staff that residents would not have an understanding of the plan in its written format. Plans for the Home would therefore be verbally discussed with residents. Mr Rodgers is currently responsible for health and safety in the Home with staff receiving training in a range of areas as detailed in the training section of this report. A senior member of staff undertakes a monthly review of the Home and garden assessing any risk issues which would then be discussed with Mr Rodgers and addressed as necessary. Gas and electrical systems are being maintained yearly. An accident book is available in the Home and was seen to meet the requirements of the Data Protection Act. The staff member on duty indicated that there is a procedure in the event of a fire in the Home and had received fire training. However, due to two residents having mobility difficulties fire evacuation risk assessments as to how staff would manage their individual needs in the event of a fire are required to be complied. This assessment will form part of the review of care plans and will be required to be kept under review. COSHH (control of substances hazardous to health) sheets are also required to be obtained for all products used in the Home with staff advised as to their content. A further area of improvement identified included a system being implemented by management to monitor temperature recording of hot food and labelling of opened foodstuff in the fridge of which records indicated were not being consistently completed by staff. This will be followed up at the next inspection. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 45 Jubilee Road (Chartwell House) Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x DS0000011746.V260269.R01.S.doc Version 5.0 Page 25 NO Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 15 Requirement The Registered Provider must ensure residents’ care plans including medication and risk assessments are up to date and kept under review. The Registered Provider must ensure there are sufficient staff on duty at all times to meet the needs of residents accommodated. This must be kept under review. The Registered Provider must ensure an assessment is undertaken by an appropriately trained professional of resident’s accessing the Home’s vehicle and having a bath. The Registered Provider must ensure documentation confirming that the hoist in the bathroom has been serviced is available in the Home for inspection. Timescale for action 25/11/05 2 YA33 18 07/11/05 3 YA19 13 25/11/05 4 YA24 13 25/11/05 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 26 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 YA18 Good Practice Recommendations A cross gender policy and procedure needs to be compiled by the Registered Provider and shared with all staff. 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 45 Jubilee Road (Chartwell House) DS0000011746.V260269.R01.S.doc Version 5.0 Page 28 - 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!