Inspection on 13/08/07 for Chaffinch Residential Care Home

This inspection was carried out on 13th August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chaffinch Residential Care Home 02/06/09

Chaffinch Residential Care Home 04/06/08

Chaffinch Residential Care Home 06/07/06

Chaffinch Residential Care Home 06/03/06

Chaffinch Residential Care Home 06/10/05

Chaffinch Residential Care Home 08/02/05

Chaffinch Residential Care Home 30/06/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Clover House

Thornton Lodge

Parkside

Park Lodge

Mere Hall View

St Bonaventures

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

CARE HOME ADULTS 18-65 Chaffinch Residential Care Home 36 Chaffinch Drive Bury Lancs BL9 6JU Lead Inspector Julie Bodell Unannounced Inspection 13th August 2007 09:30 Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaffinch Residential Care Home Address 36 Chaffinch Drive Bury Lancs BL9 6JU 0161 763 4579 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) Mr Swadesh Munbodhowa Miss Jane Ann Louise Arrowsmith Care Home 5 Category(ies) of Learning disability (1), Mental disorder, registration, with number excluding learning disability or dementia (5) of places Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum number registered there can be up to 5 MD and up to 1 LD. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6th July 2006 Date of last inspection Brief Description of the Service: Chaffinch House is a small privately owned home providing long term care and support to four people with mental health needs and one person with a learning disability. The home is situated in a residential area off Rochdale Old Road in Bury, approximately a mile and a half from the town centre. Buses and shops are within walking distance of the home. The house is a large, extended semi-detached property, with gardens at the front and back. There is room for car parking on the road. All bedrooms are single. Standard weekly fees are currently £339. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know this inspection visit was to take place. A total of five and a half hours was spent in the home, watching what went on, talking to two residents, the registered manager and a staff member, looking round the home and examining some key records. Several weeks before the visit, surveys were sent to the home to be given out to residents. None had been returned by the day of the visit. What the service does well: What has improved since the last inspection? The service user guide now includes information about how to complain. Residents are encouraged to be involved in reviews about their needs. Improvements have been made to in the décor and furnishings with many areas of the home given a fresh coat of paint. A new carpet has been fitted to the hall and stairs and a number of old wooden window frames have been replaced with new plastic frames. Three residents have had new bedroom furniture, which in two cases they had helped to choose. Residents were very pleased with the improved appearance of their rooms. Improvements have been made to hygiene in the home with the introduction of paper towels in communal washing areas. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 6 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. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed before anyone is admitted to the home, and trial visits are arranged to ensure that the home can meet both their needs and the needs of the established group of residents, safely. EVIDENCE: The home has a statement of purpose and a service users’ guide. Since the last inspection details of the complaints procedure have been included in the service users’ guide. There is a low turnover of residents admitted to the home. There have been no further admissions to the home since the last inspection. The resident most recently admitted to the home had an up-to-date CPA at the point of admission. The manager said she had visited the resident in hospital before he came to live in the home and that the resident made several visits to the home, including overnight stays, before finally moving in. The manager said that the needs of the existing resident group were taken into account before agreeing to offer a place. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices and decisions about their daily lifestyles, and are encouraged to be as independent as possible, whilst keeping any risks to their health and welfare to a minimum. EVIDENCE: Basic care plans and risk assessments relating to a resident were looked at. They had been developed from the CPA assessment and covered areas such as monitoring mental health needs, personal care, emotional needs and daily living skills. Discussions with the registered manager and staff member showed that they had a good understanding of the needs of all the residents. Risks were balanced against the resident’s right to choice and independence. Records showed that care plans and risk assessments were reviewed by the home approximately every two months. The residents who were spoken with were aware that written information was kept and knew they could see their Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 10 records if they wanted to. The resident whose file was examined had participated in reviews and had agreed and signed the care plan at each review. Residents spoken with said that they could choose how and where, they spent their time. They said they got up and went to bed at the times they chose. Most residents had their own bank accounts and looked after their own personal money. Information about local independent advocacy services was displayed in the home for the benefit of residents. Residents said that regular residents’ meetings were held during which they could express their opinions and ideas though the manager said that residents generally preferred to discuss matters on a one to one basis. Residents said that they had chosen their own colour schemes in their bedrooms Residents’ personal files were kept in a desk drawer in the office/staff bedroom. The drawer was not lockable. However, the registered manager said that the office door was always locked when the office was unoccupied and this was observed throughout the inspection. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are satisfied with their lifestyles and are happy with the quality and quantity of the food provided. Care practices in the home respect residents’ rights to privacy, dignity, choice, and independence, and they are able to keep in contact with relatives and friends. However, residents mostly access community activities independently because staffing levels only allow for limited opportunities for staff to support residents on activities outside the home. EVIDENCE: Residents were able to travel outside the home independently. This was observed during the inspection, when all residents went out pursuing their chosen activities. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 12 Two residents were spoken with and one was on holiday from college and looking forward to returning in September on a basic education course that would ultimately help to further the resident’s aspirations to work in the catering industry. The second resident was also planning to attend a similar course. The residents are good friends and went into town together to purchase some speakers for one residents CD system. The inspector was particularly pleased to see improvements in the personal development of one resident. The resident was more settled and was thinking more positively about the future. Three other residents were out visiting relatives. Two residents do this on a daily basis. The third resident visits family regularly and also attends the gym, weight watchers and the drop-in centre. Residents said that they sometimes went shopping with staff, and last year they had a holiday in Blackpool. The registered manager said that she and another staff member where keen to take residents again after a successful trip last year, but the residents’ were reluctant to go. The registered manager said that they would help and encourage people to find suitable activities, but they were rarely able to accompany residents on activities outside the home because there was normally only one staff member on duty at any one time. The registered manager said that she was confident that the registered provider would make staff time available to support residents in outside activities, where necessary. Residents said that they could choose how they spent their time. Some residents took responsibility for household tasks such as laundry, but staff undertook most of the household chores. One resident had recently been given the opportunity to move into a flat but had chosen to stay at the home. Residents were satisfied that their privacy was respected. They had keys to their bedrooms and they said that no one entered their rooms without permission. Residents said that staff treated them with courtesy and respect. This was observed during the inspection. Residents said that they generally got on well together as a group. Residents said that the meals were good and that there was enough to eat. Planned menus showed that a varied diet was provided. There was no specific alternative listed on the menu but residents knew that they could ask for something different if they wanted to and a record of the alternative was recorded. Food likes and dislikes were recorded on care files. The main meal of the day as shown on the menu for the week were, curry and rice, shepherds pie, sausage mash and beans, corn beef hash, spaghetti bolognaise, pudding chips and peas and roast Sunday dinner. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be as independent as possible, and they are involved in decisions about how staff will support them. Health needs, including medication, are kept under review and monitored closely to ensure that residents do not relapse into ill health. However, one resident does not have access to a dentist or an optician. EVIDENCE: Residents were very independent in respect of physical needs, and staff involvement in meeting personal needs was mostly in the form of prompt and encouragement. Discussions with residents showed that they had choices about their daily routines, for example what time they got up or went to bed. They said that they were happy with the way that staff members treated them, and the way they spoke to them. A good rapport between residents and the staff team was noted throughout the inspection. Residents’ weight records were kept. The registered manager and staff member knew the residents well and they described how they would quickly Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 14 pick up on any health concerns and contact the appropriate person for help and advice if necessary. There was evidence on care files of contacts with health professionals such as GPs, psychiatrists, opticians and dentists. However, it was noted that one resident is not registered with a dentist or optician and this has been the case for sometime. This needs to be addressed with the residents social worker as soon as possible. Residents confirmed that they had regular contact with health professionals. They used community based health facilities and were accompanied by a staff member if needed. No issues of concern about behavioural management were raised at this inspection. None of the residents took responsibility for their own medication. It was advised at the last inspection that residents’ agreement to staff handling of medication should be recorded either on a ‘Consent to Medication’ form, or within the care plan which the resident should be asked to sign. This has not been done for all residents. The home’s medication procedures included guidelines covering non-prescribed medication. The Boots monitored dosage system was being used. Medication was appropriately stored and medication administration records (MAR) were complete and up to date. Hand written entries were signed and countersigned. Sample staff signatures were kept with the MAR. There were records of medication received, administered, and disposed of, and also of ‘leave’ medication. No controlled drugs were being prescribed. Depot injections are administered and monitored by community psychiatric nurses. Staff training certificates showed that most staff had undertaken training in the safe handling of medicines. However, the registered provider who works at the home most weekends must receive up-to-date medication training despite their nursing qualification. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know who to complain to and they feel they would be listened to. Protection policies and procedures and staff understanding of their adult protection responsibilities ensure that the service has the means to be able to respond appropriately to any suspicion or allegation of abuse. EVIDENCE: A copy of the home’s complaints procedure was on the notice board. Residents said they would speak with the registered manager, the staff or their social worker if they had any concerns. They felt that they would be listened to. A complaints book is accessible to residents. There have been no complaints since the last inspection. There are written procedures covering adult protection, whistle blowing, and gifts, including a copy of the local authority adult protection procedures. The registered manager was clear about what action to take if a resident made an allegation of abuse. No allegations have been made since the last inspection. Adult protection needs to be included in the topics for induction training. The manager was also advised to seek out opportunities for formal training on the topic at the last inspection, and with the exception of the registered provider, this has been done. The home had a number of written policies covering equality topics such as equal opportunities, bullying, and racial harassment. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a homely, clean environment for residents suited to their lifestyles. However, there is a need for continuing improvements to ensure the home is maintained in line with current standards and expectations. EVIDENCE: The home is situated in a residential area of Bury, about a mile and a half from the town centre. It is close to bus routes, local shops, and other local amenities. The house is a large semi-detached property, and is similar to other properties in the area and does not stand out as a care home. Outside there was a gravelled area at the front, and a garden at the back where people could sit out. There was on-road parking at the front. The home had a lounge, two dining areas, a domestic style kitchen, and a small laundry room. There was a bathroom with overhead shower, and a Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 17 shower room. Each contained a toilet. The rooms were lockable to ensure privacy. All 5 bedrooms were single. All were lockable. Bedrooms were personalised with residents’ own items. The residents who were spoken with said that they were satisfied with their rooms, and with the home in general. At the last inspection it was noted that the home was looking tired in parts and there was a need for ongoing redecoration and refurbishment. Since that time many areas of the home have been given a fresh coat of paint. There has been a new carpet fitted to the hall and stairs. The home has also had a number of old wooden window frames replaced with new plastic frames. Three residents have had new bedroom furniture, which in two cases they had helped to choose and were very pleased with. The registered provider needs to produce a maintenance and renewal programme for the coming year to show what improvements are planned and the timescales. The home was clean. A cleaner works in the home 8 hours a week. Liquid soap and paper towels are now provided for hand washing in communal areas for hand drying in the interests of good hygiene. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels do not allow staff to spend much meaningful time with residents outside the home. To ensure that residents are cared for by trained staff outstanding mandatory health and safety training needs to be undertaken by all the staff team. EVIDENCE: Residents were happy with the support they received from the manager and staff members. It was observed that there was a very good rapport between residents and staff. Residents said they could go to the manager or staff at anytime and this was observed during the visit. Since the last inspection two of the staff team have achieved a NVQ Level 2 in care qualification. Two members of the staff team, which includes the registered provider, are trained mental health nurses. Staff rotas were seen. There was normally only one staff member on duty at any one time. As a result, the staff team are rarely able to spend time with Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 19 residents on meaningful activities outside the home. This staffing arrangement, although seen as acceptable prior to 31st March 2002, is insufficient to guarantee that staff will be able to have uninterrupted time working with residents. The registered manager said that she was confident that if any of the residents needed staff support for activities outside the home that the registered provider and the staff team would ensure that time was provided. There has been one vacancy that has been recently advertised and a good response to the advert was received. Suitable applicants had been interviewed and a person with many years experience in care had been appointed. The manager was in the process of gathering recruitment documentation and waiting for a CRB to be returned and written references to be taken up. An application form had been completed but a full employment history, with dates and reasons for leaving previous care jobs, had not been obtained. If the staff member has any gaps in employment, these need to be explored and evidenced why. At the last inspection records showed that new staff members received a basic induction upon commencing employment but that it did not cover all the required topics. The manager was advised again to seek information about induction standards on the Skills for Care website and contact the Local Adult Care Training Partnership for further information on induction and mandatory training. The manager carried out a training needs analysis for the home. Identified gaps in training need to be undertaken, including gaps for trained nurses. These include mandatory health and safety topics, such as first aid, food hygiene, protection of vulnerable adults, medication, and health and safety. They need to be completed as staff members generally work unsupervised. Discussion took place at the last inspection about the need for the manager to offer supervision and support in line with the needs of this small home. This might be by a combination of formal, appraisal, and team meetings. Although an improvement is noted, formal supervision arrangements need to happen more frequently. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the open and inclusive management approach but there is a need for the manager to complete NVQ Level 4 training EVIDENCE: The registered manager has restarted NVQ Level 4 after finding a new assessor. Standard 37 will not be considered met until this training has been completed. The manager has recently completed NVQ Level 2. The manager has undertaken training in topics such as mental illness, anxiety and depression, epilepsy, risk assessment, diabetes, health and safety, first aid, food hygiene, medication and dealing with challenging behaviour. The home does not have access to the Internet where there are numerous websites devoted to social care practice, including CSCI. Time was spent talking to the Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 21 registered manager about the process for Inspecting for Better Lives, including KLORA, quality ratings, annual reviews and AQAA. This discussion was limited because the home does not have Internet access to show and explain the process. It was clear, from observations and discussions, that the manager encouraged an open, inclusive atmosphere within the home. Residents said that they found her to be approachable and supportive. During the inspection, it was observed that residents had no hesitation in approaching the manager if they had anything they wished to discuss. Rotas showed that the owner of the home, an experienced psychiatric nurse, worked there at weekends, therefore Regulation 26 visits were not requested. The home had conducted a quality audit in January 2007 during which residents had been given questionnaires to complete. Feedback had been generally positive. Feedback needs to be collated and an improvement plan produced. Safety records were checked. These included portable electric appliance tests, electrical installation, gas safety, servicing of fire alarms, emergency lighting and fire extinguishers. Examination of the fire book showed that alarms, means of escape, fire fighting equipment and emergency lights had been tested weekly. The last fire drill was shown as 15.6.07. The staff team had undertaken fire training on 26.10.06. Records showed that the homes fire risk assessment was last reviewed in February 2005 and needs to be reviewed again to ensure that there have been no changes, particularly in respect of changes in smoking practices at the home to meet changes in the law. The home had a valid Employer’s Liability Insurance Certificate. Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Chaffinch Residential Care Home DS0000008423.V334564.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA19 Regulation 12 Requirement Arrangements must be made to ensure that a resident has access to a dentist and an optician to ensure that they have access to the necessary healthcare professionals they need for treatment. The registered provider must undertake appropriate training in the safe handling of medicines. The registered provider must undertake training in the protection of vulnerable adults procedure. The registered person needs to produce a maintenance and renewal plan. A copy of the plan must be sent to CSCI. The registered person needs to keep staff rotas under review to ensure that enough staff time is available to support residents on activities outside the home, and ensure levels are sufficient to fully meet residents’ needs. The registered person must ensure that a full employment history is obtained for the identified staff member. Any gaps in the employment history DS0000008423.V334564.R01.S.doc Timescale for action 30/09/07 2. 3. YA20 YA23 13 13, 18 30/09/07 30/11/07 4. YA24 16, 23 30/09/07 5. YA33 18 30/09/07 6. YA34 19 30/08/07 Chaffinch Residential Care Home Version 5.2 Page 24 must be explored and evidenced. 7. YA35 18 All members of the staff team, including qualified nurses, must undertake all the identified gaps in mandatory health and safety training relevant to their post. Staff members need to be supported and supervised by an appropriate combination of formal supervision, appraisal, and team meetings. The registered manager must complete NVQ Level 4 training in management and care. (Outstanding requirement) That the fire risk assessment is reviewed and were necessary updated to include the recent changes in smoking practices at the home. 30/10/07 8. YA36 18 31/10/07 9. YA37 9 31/03/08 10. YA42 23 30/09/07 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 YA11 Good Practice Recommendations The registered person needs to keep staff rotas under review to ensure that enough staff time is available to support residents on activities outside the home, and ensure levels are sufficient to fully meet residents’ needs. The home is advised to obtain residents’ agreement to staff handling their medication. To assist the manager to keep abreast of current good practice in social care, it is strongly recommended that she have access to the internet. 2. 3. YA20 YA42 Chaffinch Residential Care Home DS0000008423.V334564.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 Chaffinch Residential Care Home DS0000008423.V334564.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. 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