Inspection on 30/04/07 for The Chace

This inspection was carried out on 30th April 2007.

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

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

Other inspections for this house

The Chace 14/02/06

The Chace 22/07/05

The Chace 20/12/04

The Chace 07/09/04

The Chace 23/03/04

The Chace 09/12/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Chace, The Chase Road Upper Welland Malvern Worcestershire WR14 4JY Lead Inspector Yvonne South Unannounced Inspection 30th April 2007 10:30 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 Chace, The DS0000018683.V335349.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. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chace, The Address Chase Road Upper Welland Malvern Worcestershire WR14 4JY 01684 561813 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) enquiries@thechase.com www.thechace.com Chace Rest Home Limited Mr Anthony William Reeley Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (34), of places Physical disability over 65 years of age (26) Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th February 2006 Brief Description of the Service: The home provides a residential care service for a total of 34 people over the age of 65 years. The home is able to provide care for older people who are physically disabled and older people who suffer with dementia. The number of residential places for those who have a physical disability is 26. Respite care is available, as is a day care service. The premises are situated in a village location in Upper Welland, near Malvern. They consist of an original building, formerly a country manor house, and a large extension. Accommodation is provided on two levels in both parts of the building. There are fourteen bedrooms on the ground floor, twelve of which have ensuite facilities. There are eighteen bedrooms on the first floor, seventeen of which have ensuite facilities. There are four bathrooms, three of which are adapted for people with disabilities plus a shower room, also adapted for people with disabilities. Rails are provided in corridors and a shaft lift is available to assist passage between floors. A garden area is available for use by service users. There is a rural bus service close to the home. The home is owned by Chace Rest Home Limited and the registered manager is Mr Anthony William Reeley. In the pre-inspection questionnaire completed by Mr Reeley and received by the Commission for Social Care Inspection (C S C I) on 20.04.07 the fees were quoted as being between £353 per week and £600 per week. Additional charges are made for hairdressing: £7.50 to £34, chiropody: £19.25, additional incontinence pads, personal toiletries, newspapers, magazines, holidays and transport for hospital visits: retail prices. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since 14.02.06 and the information obtained during fieldwork on 30.04.07. The fieldwork took place over eight and three quarter hours during which the inspector spoke to four residents, four staff and two relatives. Documents were assessed and a partial tour of the premises was undertaken. Prior to the fieldwork the home was asked by the Commission for Social Care Inspection (CSCI) to complete and return a pre-inspection questionnaire and to distribute questionnaires to the residents, relatives and health care professionals seeking their opinions of the service. To date one response has been received from a resident who did not give their name and stated that they did not wish to speak to the inspector. Five responses have been received from relatives and one from a GP. The staffing profile in the home has undergone a change since the previous inspection as the registered provider/manager intends to withdraw from the management position. Mrs Potter the general manager has applied for registration in his stead and the deputy care manager has taken the lead regarding the delivery of care. Three senior care assistants complete the senior team. The focus of this inspection was on the key National Minimum Standards and the requirement made following the previous inspection. Assistance with the fieldwork was principally given by the manager designate Mrs Potter. What the service does well: The service provides a warm welcome to all who visit. The home is clean and tidy, well furnished and maintained. A wide range of activities and interests are provided in the home and in the community by the welfare officer, in which the residents can choose to participate if they wish. Staff are well recruited and there is a strong commitment to training. 77 of the care assistants have National Vocational Qualifications (NVQ). Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 6 A resident described the staff as excellent. A varied choice of meals is available from the daily menus and the cook is described as Good. A resident says that she enjoys her food. 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. Chace, The DS0000018683.V335349.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 Chace, The DS0000018683.V335349.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 (An intermediate service is not offered. Therefore standard 6 has not been assessed.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information and support is available to assist people in making a decision regarding admission to the home. Assessments of needs are undertaken to ensure the home can provide the care needed before a place is offered. EVIDENCE: Care staff confirmed that the Statement of Purpose and Service Users’ Guides were readily available and that when people inquired about residence in the home they were offered a tour and given copies of the documents. Details were taken and passed onto the manager. The records demonstrated that trial stays were undertaken if desired. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 9 The care records for three residents were requested; one frail person, one person with a dementia illness and one person who was also receiving care from the district nurse service. Assessment of these documents indicated that an assessment was made of the individual’s needs prior to a place being offered. The information was more limited in some records than others and some topics had not been assessed, such as skin condition, dietary preferences, emotional needs, sight and activities. It was recommended that the assessment document should be clearly titled to reflect its purpose and include all topics listed in standard 3 of the National Minimum Standards, and sufficient information be obtained on which to agree and initial care plan. None the less good brief initial care plans were seen so that staff had the information they needed on which to begin to care for the new person. Chace, The DS0000018683.V335349.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. This judgement has been made using available evidence including a visit to this service. Residents receive the personal and health care they need, and their prescribed medication in safety. Everyone is treated with respect and consideration for their privacy and dignity. EVIDENCE: The care record system was in a state of change with the information disseminated in the home. A more cohesive and simplified system was being developed. However it was observed that the three care plans that were assessed included good detail regarding how care needs would be met. There was good historical detail of the residents’ lives and interests but limited evidence of risk assessments, reviews and the involvement of residents, or with their consent their relatives, in the care planning process. The manager designate said that a dependency profile was used to identify concerns regarding pressure care and nutrition. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 11 However full assessments on these areas should be carried out on admission to provide a base line from which the work. Some documents were signed by the resident indicating some involvement. This needed to be developed in all records. The inspector was told that relatives were kept informed of changing care needs and this was confirmed in the five questionnaires that were completed and returned by relatives. An acute care plan had been drawn up to address the changed needs over a period of ill health and the daily records demonstrated that the care was being delivered and good links were maintained with health care professionals. There was no specific communication plan for one resident who reverted to her native tongue when she was ill. The manager said that the staff understood her well and communication was never a problem. The questionnaire returned by a health care professional indicated satisfaction with communication and the knowledge and skill demonstrated by the service. However the one questionnaire returned by a resident demonstrated less satisfaction. It was said that there were insufficient staff so everything was rushed. However medical support was always available when needed. Another resident told the inspector that she had received excellent health care from the excellent staff. During the fieldwork it was observed that communication links were maintained with the surgeries, and doctors were asked to visit their patients as necessary. The management of medication was assessed. It was observed that an unlocked medication fridge was in use for medication that needed cold storage. Although the inspector understood that the room in which it was placed was locked when empty it is still recommended as good practice for the fridge to be lockable. Medication was also stored in an approved controlled drugs cupboard and a medication trolley. It is also recommended as good practice for the trolley to be either locked into a room or secured to a wall when not in use. Storage was clean and well arranged. The records had been well maintained however not all handwritten additions and amendments were double signed. This is good practice to ensure accuracy. The British Pharmaceutical Society no longer supports the practice of applying duplicate labels from the pharmacist to the administration sheets following incidents when they have been attached to the wrong resident’s documents. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 12 It was recommended that when prescribed creams were applied they should always be identified by name in the records. Medication training was provided to staff in house by the manager and the deputy using the Mulberry House training system that evaluated learning. Residents’ records demonstrated that their response to medication was monitored and responded to. The questionnaire response from the health professional indicated a belief that medication was managed appropriately. It was observed that residents were treated kindly and with respect. Phone calls could be made and received in private and the post was delivered un opened to the addressee. Chace, The DS0000018683.V335349.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, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to be interested and stimulated through participation in group and solitary activities. Support is available to enable them to continue their commitment to their faith should they choose and staff also provide the contact and support for those who have a sensory impairment. A varied nutritional menu is offered so people can choose meals that they enjoy. EVIDENCE: The home employs a welfare officer to co-ordinate activities and stimulation for the residents according to their interests wishes and abilities. The pre-inspection questionnaire indicated that a wide range of activities was offered in the home and in the community including church services and visits to churches according to individual faith requirements. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 14 The manager said that the vicar called every month and in addition to the group service he visited his parishioners privately if required. It was observed in two of the records that were assessed, that there was confusion regarding the residents’ faiths. This needed to be clarified to ascertain if any support was required now or in the future. One of the residents was of Italian descent and another was French. There were generally no language difficulties as they had lived in this country for very many years, and no cultural needs had been identified that needed support from the service. The manager said that another resident had a communication difficulty and a photographic communication tool was being developed to address this. The manager said that detailed life histories were being compiled for everyone and individual support visits were undertaken with those people who preferred to stay in their room and not join group events. The resident who returned the questionnaire indicated that there was usually activities arranged that he/she could take part in. None the less a comment was made in one questionnaire response from a relative that: ‘I consider there is a lack of mental stimulation for residents’. The relatives’ questionnaires indicated that they always felt welcome and could make their visits private if they wished. A new great grand daughter was brought on a visit during the fieldwork. The home published a monthly newsletter, which provided full information of resident and staff changes in an informative and friendly manner. Ideas and suggestions for activities and outings were sought and a monthly programme of varied events planned for the month was printed. This demonstrated a range of in house and community activities that included professional entertainers and outings in the homes own transport. The manager said that large print for documents and personal 1:1 assistance was available to help those who were visually impaired. The examples of menus demonstrated that a good choice of well-balanced meals were provided and the residents said that the food was very good. Staff were observed to assist the hearing and visually impaired with tact and sensitivity. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 15 The questionnaire response from the resident stated the opinion that the food was rather repetitive but the cook was good. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Staff are appropriately recruited to ensure suitable people provide the care for vulnerable people in the home. The staff know what to do and how to support people who have concerns. Specific training and good documentation would provide further safeguards. EVIDENCE: The complaints procedure was available in the Statement of Purpose and the Service Users’ Guide. However four of the five relative questionnaire respondents indicated that they did not know the procedure. The resident who completed the questionnaire stated that he/she knew how to make a complaint and had done so. The pre-inspection questionnaire completed by the manager stated that the home had received one complaint that was partially warranted in the past twelve months. A record was not available to demonstrate how this had been investigated and addressed as is required. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 17 A complaint was made to the Commission for Social care Inspection in April 2006. This had concerned the activities programme, the environment, the laundry and the hot water supply. The issues were investigated with the home and may be the complaint referred to in the pre-inspection questionnaire. Documentation held by the Commission for Social care Inspection indicated that the issues had been investigated and where possible addressed. The inspector interviewed three staff and they were aware of the action they should take if they were in receipt of a complaint. Although they had not received formal training regarding the protection of vulnerable people from abuse the staff were quite clear of their responsibilities should they have any concerns. The staff demonstrated that they had undergone an acceptable recruitment process that had included an application form, an interview, references and checks undertaken by the Criminal Records Bureau (CRB) and a check of the Protection of Vulnerable Adults list (PoVA). However two of the files held no references and one held no evidence of checks undertaken by the CRB. The manager said that there had been some difficulty experienced during the reorganisation of offices and documents and the ‘umbrella body they had used for CRB checks had supplied phone calls relating to the outcome of checks but had not been consistent in supplying documentary evidence. A new organisation was now being used so that this was addressed. She was confident that the references and checks had been received prior to new employees commencing their work. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are able to live in a comfortable home that suits their needs. Care is taken to manage and where possible reduce the risks of cross infection. EVIDENCE: A partial tour of the premises was undertaken. It was observed to be clean, tidy, well maintained, decorated and furnished. One of the proprietors took principle responsibility for the premises. Bedrooms were well maintained, furnished and personalised. A resident said that she loved her room. One bathroom was fitted with a hoist to assist the less able and another bathroom was in use as a storage room as the residents were unable to get in and out of the standard bath unaided. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 19 It was observed that personal toiletries had been left in the communal bathroom. This could raise the risks of personal loss and cross infection. The pre-inspection questionnaire indicated that a canopy hood and gas ‘shut off’ connection had been fitted in the kitchen and redecoration continued throughout the home. It was observed that a bedroom was being attended to at the time of the fieldwork. Personal protective equipment was available for staff to use and the staff said that they had received training in infection control. This was confirmed in the pre-inspection questionnaire. The laundry was clean, tidy and well equipped. There was a large crack in the plaster by the exit door that needed attention. The resident who completed and returned the questionnaire indicated that he/she had had cause to complain about the state of his/her room. It was said; ‘It does not get cleaned as regularly as it should. Some weeks ago the dust was so thick that my daughter put in a formal complaint. In the 7 years of residence the room had not been decorated or the carpet shampooed.’ During the tour undertaken by the inspector no offensive odours were detected and no issues with general cleanliness were identified. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. Sufficient staff are well recruited and trained so that the care needs of the people in the home are addressed EVIDENCE: The pre-inspection questionnaire indicated that there were 22 care staff and 18 ancillary staff employed in the home. 17 care staff had National Vocational Qualifications (NVQ) equating to 77 . This is a very good achievement. Fifteen staff had left the home in the past twelve months. Five of these were retirements. The reasons given for four others demonstrated that the home did not retain unsatisfactory staff. The questionnaire responses indicated some concern regarding staffing levels from two relatives and one resident. A relative commented that; ’A lower staff turnover would be helpful’. The three staff interviewed by the inspector said that they considered the staffing levels to be ‘pretty good’. Cover for absent colleagues was available when necessary and colleagues were helpful. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 21 Two of the staff team were Bulgarian. There were no difficulties regarding communication, or needs identified regarding culture or faith. The pre-inspection questionnaire indicated that training was provided on induction and on a range off health and safety topics and care related matters. This was confirmed by the staff who spoke to the inspector. The pre-inspection questionnaire indicated that a training programme was being developed for the future and it was recommended that Dementia Care and PoVA training be included. The staff were confident in their roles and aware of the needs of the residents they cared for. A key worker system was being developed. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 22 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. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well managed home where due attention is paid to health and safety. However an increase in the frequency of fire safety training would provide added protection. The service is audited to ensure areas are identified that can be improved and developed for the well being of the residents. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 23 EVIDENCE: As previously stated there had been a change in the management of the home. The manager designate had achieved the Registered Manager’s Award and had almost completed the NVQ to level 4. An application had been made to the Commission for Social Care Inspection for her registration as the manager of the home. The withdrawal of the provider/manager and reorganisation of the office space had had an inevitable effect on the documentation of the home. In addition the home had relied heavily on a computer record system and the newly appointed senior staff were not confident in this method of documentation. The manager designate said that a new system was being developed that was simple, thorough and met every need. The staff told the inspector that the management was; ‘really good’, ‘approachable’, ‘supportive’ and ‘responsive.’ The resident who returned the questionnaire had lived in the home for a long time and regretted the changes in management over the years. He/she said that since the home had passed from the original owners to their sons standards had slipped and he/she hardly ever saw the present manageress. The manager designate explained that the deputy manager now maintained regular daily contact with all the residents and she was still available and about in the home each day if required. Surveys of opinions of the service were undertaken with residents and relatives by the welfare officer. These were then analysed and action was taken where necessary to improve the service. It was recommended that a copy of the analyses could be published in the Statement of Purpose and Service Users Guide to demonstrate the continual development of the home. The manager said that the care plans were audited each month, one of the providers monitored the health and safety in the home and a professional firm had undertaken a full audit last year. A full quality assurance assessment system was being implemented. The home achieved the Investors in People Award in 2005 and a Classic Homes Environment Award for a ‘homely home’ in January 2006. The manager said that the home ran a petty cash account for residents’ personal monies. Deposits were made by residents or their supporters and Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 24 accounts were maintained along with receipts for all expenditure. Monthly statements were raised. One of the providers was appointee for only one resident due to her exceptional circumstances. The information submitted with the pre-inspection questionnaire indicated that staff were receiving appropriate training in health and safety. Systems and equipment were being maintained and serviced. The documentation seen during the fieldwork endorsed this. The fire log indicated that a fire risk assessment had been undertaken. The one seen was not in great detail. However the manager said that a professional firm had undertaken a more detailed audit in October 2006. It was not available at the time of the fieldwork. Fire drills were taking place with staff and attendance was being monitored. Training was also underway however it was recommended that it be increased to take place every three months in accordance with the guidance given by the Hereford and Worcester Fire Authority. Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 25 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 26 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 OP16 Regulation 17(2) Requirement A record must be maintained that demonstrates that complaints have been fully investigated and responded to. Timescale for action 01/05/07 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 OP3 Good Practice Recommendations It is recommended that the assessment document is clearly titled to reflect its purpose and should include all information listed in the National Minimum Standard 3.3. It is recommended that the care record system should include clear assessments, risk assessments, care plans and reviews that cover all care needs and demonstrate an involvement by the resident, or with their consent, their supporter. In this way the resident is able to participate in decisions that affect their life and staff have full up to date information regarding their care. 2 OP7 Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 27 3 OP9 It is recommended that all medication storage is secure and records are maintained to reflect good practice and address the risk of loss and error. It is recommended that staff receive specific training to enable them to identify potential and actual abuse and take the appropriate action to protect the residents in the home. It is recommended that evidence is available that demonstrates that references have been taken up and staff have received clearance from the CRB and the PoVA list before they commence employment. It is recommended that fire safety training be undertaken at the frequency advised by the Hereford and Worcester Fire Authority. 4 OP18 5 OP18 6 OP38 Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Chace, The DS0000018683.V335349.R01.S.doc Version 5.2 Page 29 - 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. 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