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Inspection on 27/09/05 for Chadderton Total Care Unit Limited

Also see our care home review for Chadderton Total Care Unit Limited for more information

This inspection was carried out on 27th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Improvements were noted to residents` risk assessments as they were more accurate and had been updated if changes in the resident`s condition or circumstances had occurred. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 6Residents on the unit for younger adults were more satisfied with provision of activities and had been consulted about what they would like to do. A small kitchen has been provided for the use of the residents on the unit for younger adults. This allows residents who can to maintain life skills such as heating up snacks and making themselves a drink. New crockery has been purchased which improves the presentation of meals for residents. Residents, visitors and staff were satisfied with the staffing levels in the home and felt they were able to meet the residents` needs. Since the last inspection meetings have started for residents on the unit for younger adults who wanted separate meetings to the rest of the home to discuss specific topics which they felt were particularly relevant to them.

What the care home could do better:

Some residents are not visited in their own home or in the hospital by staff from Chadderton Total Care, before they come into the home. Whilst assessment details are obtained verbally (usually by telephone) for these residents, from a social worker, nurse at the hospital of a member of their family, the residents themselves do not have the opportunity to meet with staff and discuss personally what they feel their care needs are. The system the home uses for recording assessment information and related care plans is not always fully completed which puts residents at risk of not having their care needs met properly. The home needs to make sure that all the necessary checks and paperwork are in place before commencing a new staff member`s employment.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Chadderton Total Care Unit Middlewood Court Middleton Road Chadderton, Oldham OL9 9RS Lead Inspector Fiona Bryan Unannounced 27 September 2005 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 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 and 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. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chadderton Total Care Unit Address Middlewood Court, Middleton Road, Chadderton, Oldham, OL9 9RS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0161-627-0027 0161-628-7769 Chadderton Total Care Unit Limited Mrs M A Green CRH - Care Home 123 Category(ies) of DE - Dementia (17) registration, with number OP - Old Age (70) of places PD - Physical Disability (40) PD(E) - Physical Disability over 65 (70) Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One registered mental nurse to be on duty on Saddleworth Unit throughout each 24 hour period. Three registered nurses to be on duty between 8:00am and 9:00pm; two registered nurses to be on duty between 9:00pm and 8:00am on Lakeland and Middlewood Units. Manager to be supernumerary to the above. Two registered nurses to be on duty between 8:00am and 9:00pm and one registered nurse to be on duty between 9:00pm and 8:00am on Chadderton Unit. Date of last inspection 3 May 2005 Brief Description of the Service: Chadderton Total Care provides care and accommodation for 123 service users with a variety of needs. It is divided into four distinct suites, including care for older people with dementia (Saddleworth Suite), general nursing (Lakeland and Middlewood Suites) and a suite for younger adults with disabilities (Chadderton Suite). The suites are staffed separately with qualified staff who have the knowledge and skills to provide the appropriate care for each service user category.The home has its own physiotherapy unit and is able to offer exercise and therapy to those who require it. The home is owned by Chadderton Total Care Unit Limited, which is a private company. Accommodation is provided on the ground floor throughout the home. Fourteen rooms are single en-suite, whilst a further 93 rooms are single and are furnished with a washbasin. Ten double rooms are also available for couples or those who wish to share. The home has several courtyard areas accessible for wheelchair users and a pleasant garden with seating at the back of the building. The lounge/dining spaces are open plan and provide ample space for movement by wheelchair users. Disabled facilities are also provided. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection and spent time talking to residents, relatives and staff. This was the second inspection for the year. Areas that were identified as needing improvement at the last inspection were looked at, including care files, risk assessments, staff recruitment procedures and staffing levels, and the provision of activities and social stimulation for the residents on the unit for younger adults. Some areas were not looked at in any detail at the last inspection and were therefore assessed at this visit, such as the environmental facilities for the residents, how complaints are handled within the home and the management of residents’ personal finances. During this inspection the manager was not on duty and the inspectors were assisted by the deputy manager. What the service does well: What has improved since the last inspection? Improvements were noted to residents’ risk assessments as they were more accurate and had been updated if changes in the resident’s condition or circumstances had occurred. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 6 Residents on the unit for younger adults were more satisfied with provision of activities and had been consulted about what they would like to do. A small kitchen has been provided for the use of the residents on the unit for younger adults. This allows residents who can to maintain life skills such as heating up snacks and making themselves a drink. New crockery has been purchased which improves the presentation of meals for residents. Residents, visitors and staff were satisfied with the staffing levels in the home and felt they were able to meet the residents’ needs. Since the last inspection meetings have started for residents on the unit for younger adults who wanted separate meetings to the rest of the home to discuss specific topics which they felt were particularly relevant to them. 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. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 for older people and standard 1, 2 and 4 for adults 18-65 The home provides enough information for prospective residents to make an informed choice about where they live. Residents’ needs are assessed before they come into the home but full details are not always obtained. Prospective residents do not always meet staff from the home before admission. EVIDENCE: A service user guide in the reception area provides detailed information regarding the services the home provides. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 9 One relative confirmed that they had been given enough information for them to make an informed decision in their choice of home, and they felt that all the information they had been given at that time had been accurate. Prior to admission details about the resident’s needs are obtained verbally, usually by phone, from the resident themselves or from their representative or care manager. If at this stage there is any doubt that the individual’s needs can be met, the prospective resident is visited to obtain further information. Visiting all prospective residents prior to their admission to the home would be seen as a measure of good practice in that it would give the resident or their representatives an opportunity to meet a member of staff from the home and be reassured about the services the home would be able to offer them. The home has a system whereby the resident and/or their representative are involved in the assessment, at which time the care plans are also developed from the information they give. This is done when the resident has been actually admitted to the home. The system of recording assessment information (by completion of core care plans) led to instances where there were gaps in the information obtained as the core care plans were not always completed in their entirety. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7 More rigour is needed in the care planning process to ensure that residents’ needs are fully met. EVIDENCE: Three care files were examined. Care plans were generic, not fully completed and not always individualised to the resident. Care plans were reviewed and dated but it was not always clear when amendments had been made, which could make it difficult for staff to assess if changes to treatment or care had been effective. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 11 An improvement was noted to the risk assessment process in that they had been updated if changes had occurred. Two relatives said they were informed of any changes to the condition or care of the resident they visited and they had been very happy with the care that had been provided to their relatives. One visitor said staff knew their relative very well and were able to deal with his needs well. Two visitors said their relatives were always well presented and their personal hygiene was well maintained. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with asssistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 for older people and standards 7, 12, 13, 14 and 17 for adults 18-65 The lifestyle needs of the majority of residents are met. Residents are encouraged and assisted to maintain contact with family and friends. Staff promote residents’ choices. Meals are varied enough to suit most residents’ tastes and a fair choice of menu is offered. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 13 EVIDENCE: A social therapy activities schedule displayed on each unit offered a range of events for residents to participate in such as aerobics, newspaper reviews, reminiscence, dominoes, board games, painting, bingo, quizzes, collage making, baking and church services. One resident said there was “plenty going on but you don’t have to join in if you don’t want to”. There had been a number of outings to places such as Salford Quays and Oswaldtwistle mill. Culcheth brass band visited the home recently and residents enjoyed a concert followed by fish and chips. One resident said they enjoyed arts and crafts, painting, colouring and doing puzzles. This resident said they went out of the home with their care worker. Church of England services are held each Thursday and Roman Catholic services are held on Sunday mornings. The home has a policy regarding the maintenance of residents’ rights and a policy to address risk taking which recognises that risk taking is a part of normal life and discusses the need to allow residents to make an informed choice by setting out the foreseeable consequences of the risk taking activity. The policy also looks at the possible involvement of relatives and other support such as the social worker and other health care professionals. Several residents had specific risk assessments for activities which present a risk to them. The contact details for the advocacy service are displayed. One relative stated that he could visit when he wished – he visited nearly every day about lunchtime and stayed and had tea with his wife. Another relative stated that visiting was flexible and he visited daily. 2 residents said they could choose to have meals in their own room and the home was flexible in its routines. One resident said that the food was satisfactory and that a choice was always offered. A member of staff was observed discussing the menu with residents and residents confirmed this happened every day. Residents on the unit for younger adults were observed asking for hot drinks, which staff were quite happy to make them. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 for older people and standaed 22 for adults 18-65 Residents are confident that complaints will be dealt with properly. EVIDENCE: The home’s complaints policy is provided in the service user guide and includes timescales for response and the contact details for the CSCI. Minutes of a residents’ meeting on the unit for younger adults stated that the complaints procedure had been explained and discussed with residents. One relative said they had been given a copy of the home’s complaints procedure. Three relatives stated that they would speak to the nurse in charge or the unit manager if they had any concerns and were confident they would be addressed appropriately. A record of complaints is kept – two complaints had been recorded together with the action taken but it was not clear from the record if the complainants had been satisfied with the response. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 24 and 26 for older people and standards 24, 26, 27, 29 and 30 for adults 18-65. The home is safe, clean and comfortable for residents to live in. Bathing and toilet facilities are satisfactory. Specialist equipment is provided for residents as needed. EVIDENCE: Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 16 A partial tour of the home indicated that the home was generally clean, tidy and well maintained. A number of double-glazing units throughout the home had failed and need replacing. Rooms were personalised with residents’ ornaments, photographs and mementos. The décor was pleasant and it was reported that there was a rolling programme of redecoration. Residents said they were satisfied with their rooms. On the unit for younger adults it was reported that due to the capacity of the residents there were only two baths and a shower that could be used. Several bathrooms have been upgraded and provided very pleasant bathing facilities for residents. The bathrooms on Saddleworth suite were quite clinical and institutional. However it was reported that this suite would be re-housed in the new building on its completion. There was a noticeable lack of space for equipment, which was being stored in the internal courtyards – this creates an unpleasant outlook for some residents whose rooms look out on to these areas. These rooms are also very dark, as they get no natural light. One resident on the unit for younger adults had a possum allowing him to control his environment independently, for example by switching on or off the television and lights. He was also able to drink independently and use the nurse call system due to adaptations to the equipment. A number of specialist beds were provided. On the unit for younger adults since the last inspection a small kitchen has been provided for the use of residents, equipped with microwave, small washing machine, hob etc. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) and 33, 34 and 35 for adults 18-65. Staffing levels meet the needs of the residents. More rigour is needed in the recruitment procedures. Staff have received training which is relevant to the care they need to provide. EVIDENCE: One resident said there were always enough staff on duty and she appreciated being checked on by staff throughout the night as it made her feel safe and confident that staff were nearby. One relative said the home went through phases when they were short staffed but they tried very hard not to let it affect the residents. Two staff said staffing levels were satisfactory at the present time and agency staff were not used very much. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 18 for older people Although it was reported that POVA checks had been made prior to the employment of staff the notification of the check that was sent by the umbrella body had not been kept. This should be kept until the full disclosure certificate from the Criminal Records Bureau is received. It was reported that staff commenced employment on the basis of receiving satisfactory references and if these were not satisfactory when they arrived the staff member would be dismissed. However references must have been received before staff commence employment. Staff had received training in health and safety topics. One new member of staff said they had received induction training over 3 days that included moving and handling, fire safety, protection from abuse, the routines of the home and covered areas such as maintaining the privacy and dignity of residents and maintaining confidentiality. A notice board in reception detailed forthcoming training sessions in moving and handling, feed pumps, continence and the management of incontinence and emergency resuscitation. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s polies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 33, 35 and 38 (Older People) and Standards 23, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38 for older people and standards 8, 23, 39 and 42 for adults 18-65. Residents are consulted about how the home is run. Financial procedures protect the interests of the residents. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 20 The health and safety of residents and staff is promoted and protected but one fire door needs replacing. EVIDENCE: Monthly meetings are held of “Friends of Total Care”. One resident said they were very useful as they got to know what was going on. A residents’ meeting had been held on the unit for younger adults since the last inspection when it was identified that residents wanted smaller meetings for their unit to discuss matters that affected just their unit and not the whole home. Some of the issues raised at the meeting had not yet been addressed – feedback should be given to the residents following meetings to inform them what actions have been taken and to explain why suggestions or requests were not possible to implement. A resident satisfaction survey had been conducted in July 2005 and the results analysed. Twenty-four forms were distributed and six were returned. The survey covered areas such as social care, physical care, catering, cleaning and laundry, the general atmosphere of the home and the approachability of staff and the speed at dealing with enquiries. One resident said they were asked to complete two questionnaires per year and another resident said they had received questionnaires occasionally. One relative said they had recently received a questionnaire and had completed it. Unit managers’ meetings are held monthly and a record of minutes kept– during these meetings information is fed up and down the lines of communication. The registered person makes himself available on a monthly basis, to meet with residents, relatives or staff and gives feedback regarding any discussions he has had. One nurse said meetings were held for qualified staff about once a month but no minutes were available for these. Residents who want to keep money have an individual account with a separate ledger to clearly identify the balance in hand. Once the money held at the home rises above a certain amount the monies are deposited in a single bank account used for all residents. The interest on the account is used for social activities and a full report of how the money is spent is made at each meeting of “Friends of Chadderton Care” and a current statement is displayed on notice boards around the home. Fire safety and moving and handling lectures held every Tuesday, which all staff must attend annually. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 21 Fire alarms, emergency lighting, fire exits and fire fighting equipment are checked weekly and records of servicing and maintenance of equipment are available and up to date. A fire door on Windermere suite needs replacing. Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 22 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 3 2 x 3 2 4 x 5 2 6 N/A HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 2 x 3 3 x 3 x 3 Score Standard No 7 8 9 10 11 Score 2 x x x x Standard No 27 28 29 30 3 x 2 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x x MANAGEMENT AND ADMINISTRATION Standard No Score 31 x 32 x 33 3 34 x 35 3 36 x 37 x 38 2 Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 23 yes 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 7 Regulation 15 Requirement The registered person must ensure that care plans are accurate, dated and detail the action which needs to be taken to meet all aspects of residents health, personal and social care needs. (Timescale of 30/6/05 not met). The registered person must ensure that failed double glazing units are replaced. The registered person must ensure that new staff only commence employment following receipt of two satisfactory references. The registered person must ensure that the fire door on Windermere suite is replaced. The registered person must ensure that assessments of residents prior to their admission to the home include all the details stated in NMS 3.3 Timescale for action 30/11/05 2. 3. 19 29 23 19 31/12/05 30/11/05 4. 5. 38 3 23 14 30/11/05 30/11/05 Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 24 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 5 Good Practice Recommendations The registered person should ensure that all prospective residents are visited by a member of staff at their address prior to admission to ensure that they have the opportunity for appropriate consultation. The registered person should ensure that the record of complaints states if the complainant was satisfied with the action taken by the home. The registered person should consider replacing the bath identified on the unit for younger adults, with a disabled shower. The registered person should ensure that confirmation of a POVAFirst check is not disposed of until the disclosure certificate from the CRB is issued. 2. 3. 4. 16 21 29 Chadderton Total Care Unit F54 F04 chadderton total care U s25429 v248143 270905 stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 2nd Floor Heritage Wharf Portland Place Ashton under Lyne, OL7 0QD 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. 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