Inspection on 28/06/07 for Burrswood House Nursing and Residential Home

This inspection was carried out on 28th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Chestnut Court Newton Street Bury Lancashire BL9 5HB Lead Inspector Grace Tarney Unannounced Inspection 28th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chestnut Court DS0000069148.V337477.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnut Court Address Newton Street Bury Lancashire BL9 5HB 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) 0161 761 7526 0161 763 4260 ANS Homes Limited ** Post Vacant *** Care Home 125 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (75), Physical disability (20) of places Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 125 service users to include: Up to 30 service users in the category of DE(E) (Dementa over 65 years of age). Up to 75 service users in the category OP (old age not falling within any other category). Up to 20 service users in the category of PD (physical disability) under pensionable age. 5 of the PD service users must be 55 years and over and must not be wheelchair users. The 5 service users with a physical disability aged 55 years and over must be cared for on the nursing unit (Dunster). New Service Date of last inspection Brief Description of the Service: Chestnut Court is a purpose-built detached property that is situated in a residential area of Bury, about one and a half miles from the town centre. The home is close to main bus routes and the motorway network. Shops and supermarkets are close by. There are well -maintained and stocked gardens surrounding the building and there is enough parking to the front and the side of the home for the use of staff and visitors. The front door of the home allows a level access for wheelchair users and people who have problems climbing steps. The home is registered to care for residents with a variety of needs. On the ground floor there is a unit for elderly residents who have dementia/ mental health needs (Peel) and a further unit that at present is not in use. On the first floor there is one unit for elderly residents with nursing needs (Dunster), and another unit for elderly residents who have social care needs (Crompton). The units on the first floor are reached either by stairs or a passenger lift. Each unit has a large lounge and dining room. The majority of the bedrooms are for single occupancy and most have an en suite toilet and wash-basin. The manager told the Inspector that the weekly fees within the home ranged from £355.11 for people who have social care needs and have their care paid for by the local authority to £355.11 plus the fee paid by the PCT for the “free nursing care” contribution. For privately funded residents a fee of £50.00 per week is payable in addition to the above. Additional charges are made for private chiropody, hairdressing and newspapers. This information was received on the 16th July 2007. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection, questionnaires (comment cards) were sent out to the residents and their relatives. The questionnaires that were sent out to the residents were called Have Your Say and they asked what people thought about their care and of the quality of the service provided. . 11 comment cards were returned, 8 from residents and 3 from relatives. What they felt about the care and services provided is written in different sections throughout this report. The main focus of this inspection was on Peel and Dunster Units. Crompton Unit will be looked at in more detail on the next inspection. 2 Inspectors visited the home and were there for 8 1/2 hours. 1 Inspector spent most of the time on Peel Unit and the other Inspector spent most of the time on Dunster. During this time they looked at care records and medicine records to ensure that the health and care needs of the residents were being met. The Inspectors also looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. The Inspectors also looked at the menus and looked at what the residents had for their lunch. They also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and train their staff. How the home manages the residents’ spending money was also looked at. In order to get further information about the home the Inspectors also spent time speaking to 3 residents, 4 relatives, 2 nurses, 3 care assistants and the homes’ Manager. A copy of the last inspection report is kept in the reception area. What the service does well: The manager makes sure that the home only cares for those people whose needs the staff can meet. The residents’ care plans contain a lot of important information about what they need help with, and how they are to be cared for. The staff make sure that they continually look at anything that may be a risk to the residents. They then make sure that they write down in the residents care plan when they have done this, and what action they have taken to reduce the risk. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 6 The qualified nurses and care staff are extremely good at caring for the residents who are very ill and need lots of specialised care. Management make sure that all the necessary equipment needed for their care is available Residents feel that they are well looked after by the staff and the following comments were made both by residents and relatives: • I am very pleased with the level of care. The staff are very helpful and caring. • I would rather be in my own home but as I cant manage this is a very good home. In answer to the Question in the Have Your Say questionnaire: What do you think that this care home does well? Comments were: • Caring and attentive to residents. • Approachable and communicative when dealing with residents and families. Hard-working. A safe system is in place for managing the medicines. The home makes sure that they check care staff out properly and safely before offering them a job. The Company is making sure that the staff are properly trained. Management are good at checking out the quality of care and the services provided for the residents. What has improved since the last inspection? What they could do better: 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. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. People are properly assessed before they are admitted to the home and this gives an assurance to everybody, that a person is only admitted if the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The pre-admission assessment records for 3 residents were inspected on the Peel Unit. All three residents had undergone a detailed pre-admission assessment that was conducted by a senior nurse. This assessment looks at what help and support the prospective resident needs in all aspects of daily life – including their mental health needs. The pre-admission assessment completed by the home was also supported by assessments carried out by social workers and/or health care professionals who had come to the conclusion the prospective resident required EMI (mainly dementia) nursing care. The assessments of 2 residents on Dunster were also looked at. The home now has a new assessment document in place that allows for a detailed Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 9 assessment to be undertaken. The assessments looked at were detailed and gave a clear indication of the residents’ needs and their capabilities Standard 6 does not apply. The home does not provide Intermediate Care. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10. Quality in this outcome area is good. Care plans and care practices ensure that the residents’ needs are met in a very safe, caring and dignified way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of 6 residents were looked at, 4 on Peel Unit and 2 on Dunster Unit. These were well-organised, detailed documents and were presented in a new format that has recently been introduced throughout the home. Following admission, care plans are developed for each resident based on the pre-admission assessment, observations made following their admission and the advice of health and social care professionals who support the resident. Care plans detail the individual care and support needs a resident may have and also describes how these needs are to be met by staff. Such a record helps to ensure that the care and support residents receive is consistent. Care plans were reviewed on a regular basis and showed that relatives were consulted regarding care plans. This was confirmed during discussions with relatives on the day of inspection. . Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 11 The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. They also assessed if it was safe to use bed rails. Risk assessments were in place for whether a resident was at risk of falling. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. When a specific risk was identified an appropriate and detailed care plan (including details of referral to appropriate health care professionals) had been developed to address and minimise that risk – for example when weight loss was identified. All residents are registered with a local GP and it was evident in the care records that they had access to opticians, chiropodists, and other specialist services that individual resident’s require (such as dieticians, community psychiatric nurses and psychiatrists). Equipment necessary for the prevention and treatment of pressure sores was available and in use. The Inspector also saw that several of the residents were being cared for on specialised nursing beds. One resident had commented in the Have Your Say questionnaire: On Dunster unit we only have one hoist to share between us and Crompton Unit. This means we often have to wait a long time to use the toilet. Being old this makes us feel ill. The manager told the Inspectors that there were enough hoists and that more carrying slings were needed, had been ordered and were now in place. The following comments were made in the Have Your Say questionnaire: • I am very pleased with the level of care. The staff are very helpful and caring. • District nurses are readily available and doctors are called immediately they are needed. • My father couldnt be in better hands. Following a discussion with some of the residents they made the following comments: They are all very good. Yes, they’re good. Everything is fine. The management of residents’ medicines on Peel Unit and Crompton Unit were inspected. Peel Unit. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. The medicines were kept securely stored in a locked room and the medicine trolley was secured to the wall when not in use. The qualified nurses on Peel unit are responsible for all aspects of looking after resident’s medicines that are under Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 12 their care. 3 residents medicine records inspected had been completed properly. Crompton Unit. Overall a safe system of medicine management was in place. Medicines were stored securely and recorded accurately. Only suitably trained staff are responsible for managing the medicines. The medicines were kept securely stored in a locked room and the medicine trolley was secured to the wall when not in use. The medicine room however is very small and cramped and there is no ventilation. It was identified that the one residents’ stock of medicines was not being rotated. Staff were giving out the medicines that had been dispensed on the 28th of May 2007 instead of using the medicines dispensed earlier on the 2nd of May 2007. To make sure that out of date medicines are not given to residents, stocks should be rotated. Staff on all units were seen to be discreet when providing assistance. Staff demonstrated by example their knowledge of maintaining privacy and dignity, by knocking on doors, closing toilet doors and speaking to residents in a quiet and respectful way. A discussion with some visiting relatives confirmed that they felt the residents were treated with respect. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 14 & 15. Quality in this outcome area is good. The residents’ dietary needs are met, they have a choice in how they spend their day and find enjoyment with the activities available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspectors saw that some residents spent their day in the lounges whist others stayed in their own rooms. I resident told the Inspector that it was his choice. The residents’ routines of daily living and their social interests were recorded in their care plans. An activities co-ordinator is employed full time at the home and the daily activities were displayed on the notice boards. Comments from the Have Your Say questionnaire were: • The Activities are excellent. • Very good activities, I like the exercise times and interest clubs. • We are very pleased with the activities manager. She provides a varied and interesting programme of in-house activities and trips out. Care staff also told the inspectors that the activities person was: excellent. Residents spoken to said that their friends and families could visit whenever they wanted and that staff made them welcome. A visitor confirmed that there were no unreasonable restrictions to him visiting at the home and that visits Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 14 could be conducted in the privacy of the resident’s room or wherever they liked. Lunch was observed on the day of inspection on Peel Unit. This was a hot substantial meal. Staff served and assisted residents appropriately and residents appeared to enjoy the meal provided. One (frequent) visitor spoken to on the day of inspection spoke very positively about the quality and variety of food provided. The dining areas were clean and appropriately furnished. However the inspector is of the view that more provision in the way of tableware and condiments would enhance the dining experience for residents in the main dining room on Peel unit. The company has introduced a system called “Nite Bite.” This is where each unit has a specially prepared box of snack meals made up and menu cards to go with it. This means that residents can have snacks of their choice 24 hours a day. Any cultural or dietary needs, likes and dislikes were looked at when a resident is first admitted to the home. There were no residents in the home who had any special dietary needs because of their race or religion. Comments from the Have Your Say questionnaire were: • The menu does seem to have improved recently and she has been offered alternative choices that are perfectly acceptable. • The food could be warmer. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. People know how to complain and staff have a good knowledge and understanding of what abuse is, thereby reducing the possible risk of harm to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was displayed and it is also included in the Service User Guide. It is easy to understand and gives an assurance that complaints will be responded to within 28 days. 1 complaint has been made to the CSCI within the last 12 months. The manager investigated the issues and wrote to the CSCI with her findings. The CSCI were satisfied with the way it was investigated and the conclusions reached. A comment from the Have Your Say questionnaire was: • I know who to complain to if I have to. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with the senior staff identified that they were very aware of the procedure to follow in the event of any allegation of abuse. Training in the protection of vulnerable adults has been undertaken by staff and is ongoing. Records of training were kept on file. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. Quality in this outcome area is adequate. Despite some areas being in need of redecoration and refurbishment, the residents live in clean, suitably adapted and comfortable surroundings. . This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is level access to the front of the home and there is plenty of parking to the front and side of the home. The entrance hall is very welcoming with seating for residents or visitors. Peel Unit. Peel Unit provides accommodation for up to 30 residents who require nursing care for dementia. The unit is situated on the ground floor of the home and can only be accessed using a coded keypad system. This helps to provide a secure and safe environment for the residents. The residents are also able to access a secure garden area adjacent to the unit. On the day of inspection the unit was clean and odour was generally being managed quite well. The lounge, dining room, bathrooms toilets and bedrooms areas were inspected on this occasion. The inspectors were Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 17 informed that a major refurbishment of these areas is due to commence in September 2007. Clearly this will significantly improve the environment of Peel unit that is currently ‘tired’ and in need of upgrading. The refurbishment will include changes to the floor covering provided in resident’s bedrooms. This will significantly help in managing any bad odours. Dunster Unit. The lounge, dining room, bathrooms toilets and bedrooms areas were looked at on this occasion. The lounge and dining room were clean, warm and well decorated. There were enough toilets and bathrooms to meet the needs of the residents. Most bedrooms also had an en-suite toilet. Toilets were near to bedrooms, the dining room and the lounge. Each toilet and bathroom had a lock on the door to ensure privacy and the toilets were clearly identified. The toilets were clean and most were suitably adapted for disabled use. The one toilet in the Parker Bathroom had no aids, such as a grab handle, to assist a resident getting on or off it. Two of the bathrooms also were storing furniture such as linen skips, chairs and Zimmer frames. These items need to be removed so that residents can enjoy a bath in pleasant surroundings. A new shower room has been provided. Staff felt that this was very useful. The bedrooms were clean and odour free however some of them were in need of redecoration. The inspectors were told that a major refurbishment of the home is due to start in September 2007. A lockable facility was provided in the bedrooms for the residents to store anything that was of value to them and the doors had an over riding door lock to ensure privacy. Many of the bedrooms were wedged open with metal doorstops. This is an unsafe practice and a danger in the event of a fire. The Inspector received a letter from the Manager on the 5th of July 2007 stating that staff have been made aware that bedroom doors must not be wedged open and that discussions were ongoing in relation to the options available to allow the bedroom doors to be held open without presenting a risk. All the rooms throughout the home were centrally heated with under floor heating. Thermostatic control valves were in place on immersion baths and showers. The home was clean and mainly free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. Several of the clinical waste bins were either missing or did not have a suitable lid on. The manager agreed to sort this out as soon as she could. The Inspector received a letter from the Manager on the 5th of July 2007 stating that pedal bins were now in place in all bathrooms and toilets. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 18 Comments from the Have Your Say questionnaire were: • The domestic staff are very efficient. • The home is currently undergoing a programme of refurbishment. It is hoped that this will improve the comfort and facilities available. • Extremely fresh and clean home. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. Quality in this outcome area is good. Residents are cared for by staff that are safely recruited and properly trained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Peel Unit. The staffing provision for day duty was appropriate for the dependency levels of residents (including the 2 residents who have been assessed as requiring 1 to 1 care) at the time of this inspection. However staffing provision at night was in need of addressing to ensure all resident’s needs at night were being met appropriately. This was discussed with the general manager who agreed to review and modify the night staffing arrangements accordingly. The Inspector received a letter from the Manager on the 5th of July 2007 stating that the staffing levels on Peel Unit would be increased. Dunster Unit. Inspection of the duty rotas and a discussion with staff and residents showed that there was enough staff on duty over a 24-hour period to meet the needs of the 21 residents living in the unit. 24-hour nursing care continues to be provided by qualified nurses who are supported by suitably trained care assistants. Crompton Unit. Inspection of the duty rotas, a discussion with staff and consideration of the dependency of the residents showed that there was not enough staff on duty during the morning, to meet the needs of the 27 residents. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 20 The Inspector received a letter from the Manager on the 5th of July 2007 stating that the staffing levels on Crompton Unit would be increased and would be reviewed on a regular basis to ensure that the needs of the residents were met. Comments from the Have Your Say questionnaire were: • Always been good communications between my family and staff. A definite plus point. • The staff are very approachable and always willing to discuss care. • The staff are very helpful and caring. • The staff will always try to carry out your request within a reasonable time. • When fully staffed there are no problems but there are times when they are short staffed and this causes many difficulties. • My only observation would be that on the unit in question (Peel) there is one male staff member. Considering the demands of the job both physically and at times emotionally and the fact that there are equally as many male and female residents I consider this to be inadequate. In answer to the Question in the Have Your Say questionnaire How do think the care home can improve? One comment was: • More male staff on Peel Unit. The manager states that approximately 37 of care staff have achieved at least an NVQ2 qualification in care. NVQ training in health and social care is being provided for staff that have not yet achieved these qualifications. A thorough recruitment procedure is operated that helps protect residents from being cared for by unsuitable people. Inspection of 3 staff personnel files revealed that these staff had been properly and safely employed. They contained an application form (including health declaration), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training and further training. Induction training is provided for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. Also a wide range of appropriate and ongoing training in moving and handling, abuse, basic food hygiene, fire safety and other relevant topics are provided to staff at the home. Training provided to individual staff is recorded in detail and reviewed at frequent intervals. Staff spoken to felt their training needs were being addressed. Many felt that this made them more competent and they felt more valued in their work. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38. Quality in this outcome area is good. The home is well managed and most practices within the home protect the health, safety and welfare of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A very experienced general manager who is supported by senior nurses manages the home. She has worked for the company for several years and has achieved the Registered Managers Award. She keeps herself regularly updated in relation to management, health and safety and some clinical issues. The Company has its own Quality Assurance division and internal audits are undertaken on a regular basis. Management make sure that checks are undertaken on all areas of the home in relation to health and safety and fire issues. Regular checks are also undertaken of care plans, the incidence of any pressure sores, medications, Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 22 the kitchen, accidents, incidents, and anything else that affects the safety and well-being of the residents and staff. Questionnaires have been developed and given out to residents and relatives. The systems in place for the management of residents’ money were good. Generally only personal allowances are held by the home in a residents’ account. Individual computer records are made of all transactions and balances. Receipts are held for any purchases made and receipts are given to relatives when they deposit any “spending money” for their relative. The home had a detailed Health & Safety Policy. Fire risk assessments and risk assessments for all safe working practices were performed and outcomes recorded. The fire logbook was up-to-date. Regular checking and testing of the fire detection system, fire exits and emergency lights was undertaken and documented. As previously stated in the section on the environment, several of the bedroom doors were wedged open. This is a fire risk. Any accidents that happen are properly recorded and monitored. The information taken from the Annual Quality Assurance Assessment document that was filled in by the home ,plus a random check of some certificates , showed that the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 x x 2 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N?A 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 OP19 Regulation 23(2)(b) (d) Requirement To make sure that the residents live in a well-maintained environment, the redecoration and refurbishment programme must start by the agreed date. For the safety of residents, staff and visitors, fire doors must not be wedged open. Timescale for action 30/09/07 2 OP38 23(4)(c) (i) 28/06/07 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 OP9 Good Practice Recommendations Staff should make sure that stocks of medicines are rotated. . Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Chestnut Court DS0000069148.V337477.R01.S.doc Version 5.2 Page 26 - 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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