Inspection on 06/07/06 for Chaffinch Residential Care Home

This inspection was carried out on 6th July 2006.

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

The inspector 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 19 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 13/08/07

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 Sue Evans Unannounced Inspection 6th July 2006 10:00 Chaffinch Residential Care Home DS0000008423.V291023.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.V291023.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.V291023.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.V291023.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 March 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.V291023.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced. A total of 6¾ hours was spent in the home, watching what went on, talking to 3 residents and a visiting relative, interviewing a staff member and the manager, looking round the home, and examining some key records. Several weeks before the visit, comment cards were sent to the home to be given out to residents and regular visitors. None had been returned by the day of the visit. Written comments were however received from a GP. What the service does well: What has improved since the last inspection? Since the last inspection, the home has met two requirements that were made in order to promote the safety of the residents. These were the electrical installation check, and the servicing of fire extinguishers. One resident has benefited from the re-decoration of her bedroom and the provision of a new bed. Chaffinch Residential Care Home DS0000008423.V291023.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. Chaffinch Residential Care Home DS0000008423.V291023.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.V291023.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Needs are assessed before anyone is admitted to the home, and trial visits are arranged. Contracts are drawn up after admission but prospective residents are not given written information before admission (for example a copy of the Service Users’ Guide) to help them to make an informed choice about the home before deciding upon its suitability. EVIDENCE: The home had a Statement of Purpose and Service Users’ Guide. Discussion took place about the need to include details of the complaints procedure in the Service Users’ Guide. A newly admitted resident said that he had not been provided with a copy of the Service Users’ Guide. The manager said that information about the home had been given to him verbally during visits. Discussion took place about the need to provide a copy of the Service Users’ Guide to prospective residents at the time of referral so that they have details about the home to which they can refer to help them decide upon the home’s suitability. The home also needs to think about producing the information in different formats, such as audio, for anyone who has difficulty reading standard print. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 9 The home was also asked to make sure that residents and visitors were given information about where they could see a copy of the most recent CSCI inspection report. Pre-admission assessment information relating to 2 residents was looked at. Each had a care management assessment. The home also carried out its own brief assessment, looking at the person’s background and finding out about their likes and dislikes. The manager said that information from both sources was used to develop the person’s care plan. The manager said she had visited a recently admitted resident in hospital before he came to live in the home. She said that he came to the home for several visits, including overnight stays, before finally moving in. The resident confirmed this. The manager said that the needs of the existing resident group were taken into account before agreeing to offer a place. Discussion took place about whether the home would be equipped to meet the needs of residents from ethnic minority groups. The manager said that she would find out about a person’s specific needs, for example diet, by consulting with relevant people such as social workers, relatives or religious leaders. Copies of contracts were held on personal files. They contained details about the terms and conditions, and services provided. The contract relating to the most recently admitted resident had been signed by the resident, the home’s manager, and the resident’s social worker. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the 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. They feel that their confidences are kept. However, they need to be encouraged to have more involvement in the running of the home, and in care planning and reviewing. EVIDENCE: Care plans and risk assessments relating to 2 residents were looked at. They had been developed from the care management assessments. They covered areas such as personal care, emotional needs, daily living skills and medication. Discussions with the manager and staff member showed that they had a good understanding of the needs of the residents. They were consistent in how they described the residents’ needs. However, the care plan for one resident did not include details of a key component of his identified needs. This needs to be addressed. Residents described some of the things staff Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 11 helped them with and this matched the information given by the manager and staff member. Risks were balanced against the resident’s right to choice and independence. For example, residents were asked to inform staff members if they were going to be out after 10pm, and they were advised about using a safe means of transport home. In one case, other professionals had been consulted when the home felt that one resident’s particular lifestyle choice was posing a risk to her health and well-being. Records showed that care plans and risk assessments were reviewed by the home approximately 2 monthly. However, in the case of one resident, the last care management review notes were dated 2002. The manager said that there had been a number of reviews since then. She was asked to locate the records. The residents who were spoken with were unsure about what written information was kept, but knew they could see their records if they wanted to. They could not recall participating in reviews. The manager said that they used to be involved but had lost interest. She was asked to talk to each resident about their care plan and encourage them to be part of the reviews. Residents should be asked to agree and sign care plans and updates. Those spoken with during the visit were satisfied with the support provided. A resident said, “Staff help with problems”. Another said of staff, “If I want to talk something over I can see them”. The GP who provided written comments said that staff demonstrated a clear understanding of the care needs of the residents. Residents 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. This was noted at the start of the inspection visit when one resident was still in bed. Most residents had their own bank accounts and looked after their own personal money. However, 2 residents had asked the home to look after some of their personal money to help them budget. Appropriate records of these transactions were kept. No one had an independent advocate. The manager was advised to seek information about local independent advocacy services, and display the information 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. The home had conducted a quality audit last November during which residents had been given questionnaires to complete. The manager said that residents chose their own colour schemes, and that she was planning to go shopping with a resident to help her choose a window blind for her room. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 12 Discussion took place about extending residents’ involvement perhaps by including them in choosing interview questions for new staff, or by seeking their opinions when updating documents such as the Service Users’ Guide. The staff member who was spoken with demonstrated an understanding of what confidentiality means. Residents said they were confident that staff members would keep their personal details confidential. Residents’ personal files were kept in a desk drawer in the office/staff bedroom. The drawer was not lockable. However, the manager said that the office door was always locked when the office was unoccupied. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the 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 two residents went out pursuing their chosen activities. When asked about the kind of activities they took part in, one resident described a college course she had just finished. She said she hoped to begin a new course in September. Another said she hoped to start going to a local drop-in centre in September. They said that they sometimes went shopping with staff, and last year they had a holiday in Blackpool. A third resident said that he rarely went out. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 14 The staff member said that one resident attended local drop-in centres. Another used to go to a gym but had given it up now. The manager and the staff member 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. It was noted that staff kept records of the activities that people took part in. Residents and staff said that residents were included on the electoral roll. It was clear, from discussions and observations, that residents were encouraged to maintain contact with family and friends if they wanted to do so. It was observed that 2 residents had visitors on the day of the inspection visit. A note on the office noticeboard stated that there was an open visiting policy but visitors were asked to leave the premises by 11pm. 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. Residents were satisfied that their privacy was respected, for example they had keys to their bedrooms and they said that no-one entered without permission. Residents said that staff treated them with courtesy and respect. This was observed during the inspection. Residents said that the meals were good, there was enough to eat, and that there were choices. One described the meals as “lovely” and “tasty”. They said that if anyone was out at mealtime, their meal would be saved until later. Planned menus showed that a varied diet was provided. There was no specific alternative listed but residents knew that they could ask for something different if they wanted to. Food likes and dislikes were recorded on care files. The manager and staff member gave examples of the food that one resident disliked and this matched with what the resident said. Nutritional assessments were seen on file. The manager described how she had sought advice from other professionals due to concerns about whether one resident was getting enough food and fluids. The last Environmental Health food safety inspection took place on 18/1/06. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. 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 the service. Residents are assisted to be as independent as possible, and they are included in decisions about how staff will support them. Health needs are kept under review, and medication storage and procedures promote good health and safety although 1 staff member needs to undertake appropriate medication training. EVIDENCE: Residents were very independent in respect of physical needs, and staff involvement in meeting personal needs was mostly in terms of prompt and encouragement. The manager and staff gave examples of this in respect of 2 residents. 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. Accident records were kept. Residents’ weight records were kept. The manager and staff member knew the residents well and they described how they would quickly pick up on any health concerns and contact the appropriate Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 16 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. 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. None of the residents took responsibility for their own medication. It is advisable 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. 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 and most MAR had a photograph of the resident attached. There were records of medication received, administered, and disposed of, and also of ‘leave’ medication. No controlled drugs were being prescribed but the home had appropriate storage, and a controlled drugs book, in case the need should arise in future. Staff training certificates showed that most staff had undertaken training in the safe handling of medicines. However, a staff member who commenced employment at the home in October 2005 had not done the training. This needs to be rectified. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. 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 the 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, but adult protection is not included in the staff induction training list. EVIDENCE: A copy of the home’s complaints procedure was on the noticeboard. The most recently admitted resident did not have a personal copy. Other residents weren’t sure if they had been given a copy, although the personal file for one person showed that she had signed confirmation that she had received one. Residents said they would complain to the manager or their social worker if they had any concerns. They felt that they would be listened to. Discussion took place with the manager about the value of recording all concerns and suggestions, even relatively minor things, as they provide a good source of information about ways that the home can improve its service. There were written procedures covering adult protection, whistle blowing, and gifts. The staff member who was interviewed understood her responsibilities in reporting any suspicions of abuse. The manager said that she made sure that staff understood their responsibilities in this area. However, 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. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 18 As already stated in this report, the home looked after personal cash sums for two residents. Cash was safely stored and there were records of incoming and outgoing sums. The home had a number of written policies covering equality topics such as equal opportunities, bullying, and racial harassment. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home provides a homely, clean environment for residents suited to their lifestyles. However, there is a need for continuing improvements to ensure that standards are 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. Thus it 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 communal rooms, 3 bedrooms, and the bathrooms and toilets were looked at during this inspection. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 20 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 shower room. Each contained a toilet. The rooms were lockable to ensure privacy. The toilet seat in the shower room needed replacing. All 5 bedrooms were single. All were lockable. Three were looked at this time. One had recently been re-decorated and the resident was pleased with it. Bedrooms were personalised with residents’ own items. The home was clean. A cleaner works in the home 8 hours a week. Liquid soap was provided for hand washing in communal areas but cotton towels were being used for hand drying. In the interests of good hygiene, the home needs to provide paper towels in these areas. The residents who were spoken with said that they were satisfied with their rooms, and with the home in general. However, some areas were looking a little tired, and there remained a need for ongoing redecoration and refurbishment. The manager said that the next room to be redecorated would be the dining room, and that it was planned to work through the home until all areas had been done. There was no written maintenance and renewal plan. The provider needs to produce a maintenance and renewal programme for the coming year to show what improvements are planned and the timescales. The renewal plan needs to be updated each year. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the 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, the home needs to have at least 50 of care staff trained to NVQ level 2, and more topics need including in staff induction training. Recruitment practices need to be more robust in order to fully protect the welfare of residents. Staff members need to have more regular individual supervision and appraisal to help them to develop professionally. EVIDENCE: Residents were happy with the support they received from the manager and staff members. It was observed that there was a good rapport between residents and staff. Residents said they could go to the manager or staff at any time. This was observed during the visit. None of the staff team had an NVQ care qualification. This means that the home is not achieving the standard of having 50 of support workers qualified to NVQ level 2. The manager said that she and another staff member had just started the NVQ level 2 course. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 22 Staff rotas were seen. There was normally only one staff member on duty (including the manager) at any one time. As a result, the staff team were rarely able to spend time with residents on meaningful activities outside the home. There was also a need to juggle priorities if several things needed attention at the same time. 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 impact of this minimal staff cover on the manager’s role is looked at in the next section of this report. The registered provider needs to review staffing levels to ensure that they are sufficient to fully meet residents’ needs. Recruitment documents for the 2 most recent recruits were looked at. It was noted that CRB (Criminal Records Bureau) checks had been done, criminal convictions declarations obtained, and 2 written references taken up. Application forms had been completed but in one case 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. There was no photograph for one person, and neither staff member had completed a statement to confirm that they were physically and mentally able to undertake the work described in the job description. Records showed that new staff members received a basic induction upon commencing employment. It did not cover all the required topics. The manager was advised to seek information about induction standards on the Skills for Care website. The manager and staff member gave examples of some of the training that they had undertaken. A sample of training certificates were looked at. They included specialist topics such as anxiety and depression, epilepsy and diabetes, as well as the mandatory health and safety topics, such as first aid, food hygiene, medication, and health and safety. The manager said that the most recently recruited care worker still needed to do first aid, medication, and food hygiene. These need to be completed as a priority given that this person works unsupervised. The staff member who was spoken with felt that she had enough support from the manager and she felt comfortable in approaching her at any time. However, examination of records showed that formal, individual staff supervision meetings were not taking place very frequently. The manager was aware of this but said that she talked to staff during handover periods. Discussion took place 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 and informal supervision and appraisal, and team meetings. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from the open, inclusive management approach but there is a need for the manager to complete the NVQ level 4 training, and to have dedicated management hours, to assist her in carrying out her management responsibilities. EVIDENCE: The manager is registered with the CSCI. She said that she had previously begun NVQ level 4 training but this had been put on hold whilst she found a new assessor. Standard 37 will not be considered met until this training has been completed. The manager said she had found a new assessor now and hoped to re-start the course soon. As already stated under the ‘Staffing’ section of this report, the manager and a staff member have just begun the level 2 NVQ course. The manager said that she would be doing both NVQ courses at the same time. Examination of training certificates showed that the manager had undertaken training in topics such as mental illness, anxiety and depression, epilepsy, risk Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 24 assessment, diabetes, health and safety, first aid, food hygiene, medication and dealing with challenging behaviour. In order to keep abreast of current good practice, the manager needs to have access to current information and guidance. The home does not have access to the Internet where there are numerous websites devoted to social care practice. It is recommended that the manager be given access to this. Rotas showed that the owner of the home, an experienced psychiatric nurse, worked there at weekends. The manager was included in the normal rota and worked on her own from Monday to Friday from 9am to 5pm. She had no super-numerary management hours. Her duties therefore include attending to all service users’ needs, cooking, answering telephone queries, administering medication and money, and completing daily paperwork, as well as her management duties. An off duty worker came in to cover for part of the inspection so that the manager would be free to assist the inspector. Nevertheless, there were interruptions whilst the manager answered the telephone or the door, or when residents needed to see her for various reasons. Whilst it was felt to be commendable that the manager was not a remote figure and was spending useful time with residents, it was also felt that she needed to be able to set aside a number of hours per week in order to carry out management and development tasks. 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. Regular meetings took place for residents, where they could express their views. During the inspection, it was observed that residents had no hesitation in approaching the manager if they had anything they wished to discuss. The home had carried out a satisfaction survey with residents last November. The manager said that, because all the feedback had been positive, an improvement plan had not been produced. Discussion took place about the need to carry out a further satisfaction survey this year. Next time, the home needs to widen the scope of its questionnaires to include residents, relatives, staff, and others who are regularly in contact with the home, for example social workers. The manager and owner need to use this information, in conjunction with their own self-audit, to produce an improvement plan that will show residents, and others, that their views are being listened to and acted upon. Several safety records were checked. These included portable electric appliance tests, electrical installation, servicing of fire alarms and emergency lighting, servicing of fire extinguishers, and servicing of the intruder alarm. The gas safety check, undertaken on 7/2/06 referred to a faulty appliance that was said to be a risk. It was unclear from the documents whether this fault Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 25 had been addressed. The manager immediately contacted the gas safety engineer and arranged for him to visit. Records showed that the home had done a very basic fire risk assessment although the manager said that the fire safety officer had found it acceptable. 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 21/6/06. The last recorded fire training was on 8/02/05 so a refresher needs to be arranged. Records showed that hot water temperatures were regulated. The home had a valid Employer’s Liability Insurance Certificate. Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 26 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 2 2 3 3 X 4 3 5 3 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 3 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X X 2 X Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 27 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 YA1 YA22 Regulation 5, 22 Timescale for action The Service Users’ Guide needs 31/08/06 to include details of the home’s complaints procedure. A copy of the Service Users’ Guide and Complaints Procedure must be given to each service user. The care plan for the identified 31/08/06 resident needs expanding. The home needs to encourage resident participation in care planning and reviewing, and ask them to sign their agreement to the plans. Care Management reviews must be available for inspection. 3. YA14 YA33 YA37 18 The registered person needs to 30/09/06 review staff rotas with a view to allowing staff members more time to support residents on activities outside the home, and ensure levels are sufficient to fully meet residents’ needs. There is also a need to ensure that the manager has sufficient hours in which to concentrate on DS0000008423.V291023.R01.S.doc Version 5.2 Page 28 Requirement 2. YA6 15 Chaffinch Residential Care Home her management including individual supervision. 4. YA20 13 duties, staff The identified staff member must 30/09/06 undertake appropriate training in the safe handling of medicines. Staff induction training must 31/08/06 include the topics required by Skills for Care. This includes adult protection. The registered person needs to 30/09/06 produce a maintenance and renewal plan which includes the redecoration and refurbishment of the dining room, stairway, and some bedrooms. A copy of the plan must be sent to the CSCI by the date in the end column. (Refurbishment of the home has been an ongoing requirement from previous inspections) The identified toilet seat needs 11/08/06 replacing. Paper towels must be provided 11/08/06 for hand drying in communal areas. The home must support and 31/12/06 encourage staff to undertake NVQ training. (Ongoing requirement) The registered person must 11/08/06 ensure that a full employment history is obtained for the identified staff member. Any gaps in the employment history must be explored. A photograph must be obtained for the identified staff member. Staff members must complete a 5. YA23 YA35 13, 18 6. YA24 16, 23 7. 8. YA24 YA30 23 16 9. YA32 18 10. YA34 19 Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 29 declaration confirming that they are physically and mentally able to undertake the work outlined in their job description. The registered person must inform the CSCI, by the date in the end column, of the action taken to address this requirement. 11. YA35 18 The identified staff member must 31/10/06 undertake training in first aid and food hygiene. Staff members need to be 31/10/06 supported and supervised by an appropriate combination of formal supervision and appraisal, informal supervision and team meetings. The registered manager needs to 30/09/06 re-start her NVQ Level 4 training in management and care. (Ongoing requirement) The registered person must 11/08/06 notify the CSCI in writing, by the date in the end column, of the outcome of the visit by the gas safety engineer. The manager needs to arrange for a refresher course for staff in fire safety training. 30/09/06 12. YA36 18 13. YA37 9 14. YA42 23 15. YA42 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 30 1. YA1 The registered person needs to think about producing information such as the Service Users’ Guide in formats other that print (for example audio) for anyone who may have difficulty reading standard print. The home is asked to make sure that residents and relatives have information about where they can see a copy of the most recent inspection report. The registered person is advised to seek, and display in the home, information about independent advocacy services. The home is advised to try to extend residents’ involvement in the running of the home, for example they might be asked to choose interview questions for new staff. The home is advised to obtain residents’ agreement to staff handling their medication. The home is advised to seek out opportunities for formal staff training in adult protection. To assist the manager to keep abreast of current good practice in social care, it is recommended that she have access to the internet. 2. YA1 3. YA7 4. YA8 5. 6. 7. YA20 YA23 YA42 Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Chaffinch Residential Care Home DS0000008423.V291023.R01.S.doc Version 5.2 Page 32 - 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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