Inspection on 04/06/08 for Chaffinch Residential Care Home

This inspection was carried out on 4th June 2008.

CSCI found this care home to be providing an Adequate service.

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 11 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 13/08/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Chaffinch Residential Care Home 36 Chaffinch Drive Bury Lancs BL9 6JU Lead Inspector Julie Bodell Unannounced Inspection 4th June 2008 09:30 Chaffinch Residential Care Home DS0000008423.V365435.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.V365435.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.V365435.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.V365435.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. 13th August 2007 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.V365435.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The home did not know this inspection visit was to take place. A total of five hours was spent in the home. We (the commission) talked to two people that live at the home, the registered manager and a staff member. We looked round the home and at some key records. We received information requested (AQAA) before this visit from the service provider. We also received a feedback survey from each person living at the home, three relatives and a staff member, which made positive comments about the home. What the service does well: What has improved since the last inspection? Work has been undertaken to improve the environment including some new furniture in the lounge, new worktops in the kitchen, a number of new beds and some decorating. The staff team has now undertaken most of the mandatory heath and safety training that they need to carry out their role safely. The registered manager is making steady progress towards completing her NVQ Level 4 in care and management. Members of the staff team are no receiving regular supervision from the registered manager. Chaffinch Residential Care Home DS0000008423.V365435.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.V365435.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.V365435.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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People thinking about going to live at Chaffinch Drive are assessed to ensure that their individual needs and those of people already living at the home can be effectively and safely met. EVIDENCE: For people considering a move to the home a community psychiatric assessment would be undertaken by a qualified person to ensure that it was a suitable placement for them. The registered manager has told us previously that she would visit people at home or in hospital to make an assessment on the part of the home to ensure that individual needs could be met. The manager said that the needs of the existing group of people living at the home would also be taken into account before agreeing to offer a place. People were able to visit the home, including overnight stays, before finally making the decision to move in. There have been no new people come to live at the home for sometime. We spoke to two people who live at the home who both confirmed that they were happy at Chaffinch Drive and that the group got on well together. When people come to live at the home they are given a copy of the service user guide, a copy of the complaints procedure and information about an advocacy service that they can use if they have any concerns. Chaffinch Residential Care Home DS0000008423.V365435.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to make choices and decisions about their daily lifestyles but a person centred approach to support by the home, could be developed further. EVIDENCE: Care plans and risk assessments relating to two people were looked at and were seen to be basic. One person’s plan had been developed from their CPA assessment and covered areas such as monitoring mental health needs, personal care, emotional needs and daily living skills. This person had not had a CPA review for sometime and it was clear from records and discussion with the registered manager that their had been changes in their behaviour and health care needs recently. The registered manager said that she would check this out with the community psychiatric nurse and make any necessary arrangements. Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 10 The records of a second person living at the home but who has different needs were looked at. There has been a review of the appropriateness of the service to check that the home is meeting this person’s specific needs. Some shortfalls have been identified around the lack of a person centred approach, activities and relevant training for the staff team. The reviewing officer has advised the home about where they could access training to help the staff team to develop and keep up-to-date with current practice. We spoke to the person concerned who said that they were happy with the current arrangements and wanted to remain at the home. Discussions with the registered manager and the staff member confirmed that they had a good understanding of the needs of people living at the home. Records showed that care plans and risk assessments were reviewed regularly by the home. However when people’s needs change the registered manager needs to update risk assessments to ensure that the staff team have accurate information and clear direction about how they are to support people. This needs to include risk assessments around self-medicating. People 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 people have their own bank accounts and looked after their own personal money. People we spoke with were aware that written information was kept and knew they could see their records if they wanted to. People’s personal files were kept in a desk drawer in the office/staff bedroom. The drawer was not lockable. However, the office door was always locked when the office was unoccupied and this was observed throughout the inspection. Chaffinch Residential Care Home DS0000008423.V365435.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): 11 12 13 14 15 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who come to live at the home need to be able to access community activities independently because staffing levels limit opportunities for staff to support them outside the home. EVIDENCE: People who live at the home are able to travel independently using public transport. Three people were out visiting relatives, which they do on a daily basis and one was also going to call into the gym on the way home. A fourth person was at college doing a basic skills course, which they attend four days a week. They too visit their family at the weekend. The fifth person was currently completing an application form for a part-time job at a local supermarket. People spoken with said that they could choose how they spent there time. Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 12 Some people take responsibility for some household tasks. One person has an activity timetable that involves attending a drop in centre and doing household tasks around the home. A small plastic green house has been purchased so that people can get involved in gardening. The registered manager said that they would help and encourage people to find suitable activities and would accompany people on activities outside the home whenever possible. There is only one staff member on duty at any one time but the registered manager said that she was confident that the registered provider would make staff time available to support people where necessary. Recently the registered manager has been to the cinema with a person on a one to one basis and there are plans for this to happen again in the coming weeks. A group trip out to go bowling is also planned. People were satisfied that their privacy was respected. They have a key to their bedroom and they said that no one entered their rooms without permission. Most people had their own television and sound system in their bedrooms and one person was watching a DVD. People said that staff treated them with courtesy and respect. This was observed during the inspection. People said that they generally got on well with each other as a group. One person living at the home said in a returned survey that, “I enjoy living here.” People said that the meals were good and that there was enough to eat. The registered manager had done the shopping for the home on the day of the inspection and ample supplies appear to have been purchased. Planned menus showed that a varied diet was provided. There was no specific alternative listed on the menu but people knew that they could ask for something different if they wanted to and a record of the alternative was recorded. The main meal of the day as shown on the menu for the week were, curry and rice, Spaghetti Bolognese, eggs waffles sausage and beans, beef stew and dumplings, baked potatoes and tuna, steak and chips and a Sunday roast. Chaffinch Residential Care Home DS0000008423.V365435.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 good. This judgement has been made using available evidence including a visit to this service. Health needs, including medication, are kept under review and monitored closely to ensure that people do not relapse into ill health. EVIDENCE: People living at the home are very independent in respect of physical needs, and staff involvement in meeting personal needs is mostly in the form of prompt and encouragement. Discussions with people 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. Weight records were kept. The registered manager knew the needs of people well and they described how they would quickly pick up on any health concerns and contact the appropriate person for help and advice if necessary. This was evidenced in a recent change in the behaviour of a person. There was evidence on care files of contact with healthcare professionals such as GPs, Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 14 psychiatrists, psychologists, opticians and dentists. No major issues of concern about behavioural management were raised at this inspection. People have signed a consent form agreeing that members of the staff team can administer their medication. 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. 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. The registered provider, who works at the home most weekends, has still not undertaken up-to-date medication training. One person has recently become responsible for their medication outside the home during the day. A risk assessment needs to be undertaken to ensure the safety of both the person and the medication in transit. Chaffinch Residential Care Home DS0000008423.V365435.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 adequate. This judgement has been made using available evidence including a visit to this service. All the staff team would benefit from undertaking updated safeguarding vulnerable adults awareness and procedure training to ensure they are able to respond appropriately to any suspicion or allegation of abuse. EVIDENCE: People said they would speak with the registered manager if they had any concerns. They felt that they would be listened to. A complaints book is kept on the kitchen table for people to write in any concerns they have. This book has been used once since the last inspection and the registered manager has dealt with this matter. The home has received a copy of the new local authority safeguarding vulnerable adults procedures. No allegations have been made since the last inspection. The registered manager when asked was not clear about the role of the safeguarding co-ordinator but would contact the local authority or CSCI if she had any concerns. All the staff team have undertaken vulnerable adults procedure training in the past with the exception of the registered provider, where apart from the date the training took place, there is no other evidence to confirm that the training has been done. It is strongly recommended that all the staff team undertake training on the new safeguarding procedure through the local authority training initiative to ensure they are able to respond appropriately to any suspicion or allegation of abuse. Chaffinch Residential Care Home DS0000008423.V365435.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 and clean environment but there is a need for continuing improvements to ensure that standards are maintained. EVIDENCE: The home has a lounge, two small dining areas, a domestic style kitchen, and a small laundry room. There is a bathroom with overhead shower, and a shower room. Each contained a toilet. The rooms were lockable to ensure privacy. All bedrooms were single and lockable. Bedrooms were personalised with peoples’ own possessions. People we spoke with said that they were satisfied with their rooms, and with the home in general. It was noted that two bedrooms require redecoration. 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 the registered manager said that a number of improvements have been made Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 17 including, some new furniture to the lounge, new work tops in the kitchen, some new beds and some decorating had been carried out. The registered provider needs to produce a maintenance and renewal programme to show what improvements are planned for the coming year. The home was clean and tidy. A cleaner works at the home for 8 hours a week. Liquid soap and paper towels are provided for hand washing in communal areas for hand drying in the interests of good hygiene. Chaffinch Residential Care Home DS0000008423.V365435.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 33 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. To promote the staff teams continuous professional development training in person centred planning, equality and diversity, The Mental Capacity Act and further mental health training needs to be considered, which will be of benefit to people living at the home. EVIDENCE: People were happy with the support they received from the registered manager and staff members. It was observed that there was a very good rapport between people and staff members on duty. Two of the current staff members are retired psychiatric nurses. Copies of their qualifications need to be kept on their files. The registered manager holds a NVQ Level 2 and is currently undertaking NVQ Level 4 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 people on meaningful activities outside the home. This staffing arrangement, Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 19 although seen as acceptable prior to 31st March 2002, is insufficient to guarantee that staff will be able to have uninterrupted time working with people. The registered manager said that she was confident that if anyone needed extra staff support that the registered provider and the staff team would ensure that time was made available. A staff member in a returned survey stated under what the service could do better, “Nothing really, everything that could be possibly done for clients is done willingly.” There is one vacancy that has been recently advertised. Suitable applicants had been interviewed and a person was in the process of being considered. The manager was in the process of gathering recruitment documentation. 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. This matter was raised at the last inspection. 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 registered manager has carried out a staff training needs analysis for the home and, with the exception of the registered provider, identified gaps in training have been undertaken. These include mandatory health and safety topics, such as first aid, food hygiene, medication, and health and safety. Now that most of the mandatory health training has been completed it is strongly recommended that to promote the staff team’s continuous professional development that training is undertaken in person centred planning, equality and diversity, The Mental Capacity Act and further mental health training. Improvements were noted in the frequency of formal supervision. Chaffinch Residential Care Home DS0000008423.V365435.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. The registered manager is making steady progress in completing NVQ Level 4 training but some health and safety shortfalls need to be addressed. EVIDENCE: The registered manager is making good progress in NVQ Level 4 and said that she has now completed four units. The manager has completed NVQ Level 2 and 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. It was clear, from observations and discussions, that the manager encouraged an open, inclusive atmosphere within the home. Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 21 Rotas showed that the owner of the home, an experienced psychiatric nurse, worked there at weekends, therefore Regulation 26 visits are not required. The home had conducted a quality audit in January 2007 during which people had been given questionnaires to complete. Feedback had been generally positive. The home is intending to put out new questionnaires in the near future. Before this inspection visit we asked the home to complete our Annual Quality Assurance Assessment (AQAA). The registered provider completed the form and the information provided to us was limited. The home still does not have access to the Internet where there are numerous websites devoted to social care practice, including the CSCI professional site and Skills for Care. The registered manager said that the registered provider was intending to have a broadband line installed at the home and was going to purchase a laptop. The registered manager was informed that if the home took up membership with the local authority training partnership then they would provide the home with a laptop to use free of charge. 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 18.12.07. The staff team had undertaken fire training in April 2008. Records showed that the homes fire risk assessment was last reviewed in February 2005 and despite a requirement made at the last inspection has not yet been reviewed. This needs to be done because since the changes in the law, people who smoke at the home are now doing so in their bedrooms, which increases the risk of a fire. The fire door to the main lounge is not closing to the rebate because the carpet grip is preventing it and therefore will not give protection from smoke in the event of a fire. One person is also heavily using an extension block for plugs in their bedroom, which also increases the risk of an electrical fire. During this inspection there was an accident involving a staff member leaving the premises. The staff member misjudged the end of the handrail and fell into the garden sustaining a fractured wrist. The registered provider must ensure that the rail is extended to prevent this happening again. The home had a valid Employer’s Liability Insurance Certificate. Chaffinch Residential Care Home DS0000008423.V365435.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 X 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 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Chaffinch Residential Care Home DS0000008423.V365435.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 YA9 Regulation 13 Requirement The registered manager needs to update risk assessments and request a CPA review for an identified service user to ensure that the staff team are given up to date and clear direction about how to support this person given their changing needs. This should include a risk assessment about self-medicating. The registered provider must undertake appropriate training in the safe handling of medicines. (Outstanding 30/09/07) The registered provider must undertake training in the protection and safeguarding of vulnerable adults procedures. (Outstanding 31/11/07) The registered person needs to produce a maintenance and renewal plan for the next 12 months. 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 DS0000008423.V365435.R01.S.doc Timescale for action 31/07/08 2. YA20 13 31/08/08 3. YA23 13, 18 31/08/08 4. YA24 16, 23 31/08/08 5. YA33 18 30/09/08 Chaffinch Residential Care Home Version 5.2 Page 24 fully meet residents’ needs. 6. YA34 19 The registered person must ensure that a full employment history is obtained for the identified staff member. Any gaps in the employment history must be explored and evidenced. (Outstanding 30/08/07) The registered person shall ensure that the manager complete NVQ Level 4 training in management and care. That the fire risk assessment is reviewed and were necessary updated to include the recent changes in smoking practices at the home. (Outstanding 30/09/07) The fire door between the lounge and the hall needs to be able to close to the rebate to ensure the protection of people from smoke inhalation in the event of a fire. The over use of plugs in a persons bedroom needs to be reviewed to ensure that arrangements are safe. The handrail to the front step needs to be extended to prevent any further accidents happening. 31/07/08 7. YA37 18 30/09/08 8. YA42 23 31/07/08 9. YA42 13 30/06/08 10. YA42 13 30/06/08 11. YA42 13 30/06/08 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. 2. Refer to Standard YA6 YA11 Good Practice Recommendations It is strongly recommended that the staff team undertake training in person centred planning to help them improve the present care plans and develop good practice. The registered person needs to keep staff rotas under review to ensure that enough staff time is available to support people to become involved in activities outside the home, and ensure levels are sufficient to fully meet DS0000008423.V365435.R01.S.doc Version 5.2 Page 25 Chaffinch Residential Care Home 3. YA35 4. YA42 peoples needs. It is strongly recommended that to promote the staff team’s continuous professional development that training is undertaken in person centred planning, equality and diversity, The Mental Capacity Act and further mental health training. To assist the registered manager and the staff team to keep up with good practice in social care and communication with others, it is strongly recommended that they have access to the Internet. Chaffinch Residential Care Home DS0000008423.V365435.R01.S.doc Version 5.2 Page 26 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.V365435.R01.S.doc Version 5.2 Page 27 - 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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