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Inspection on 06/03/06 for Chaffinch Residential Care Home

Also see our care home review for Chaffinch Residential Care Home for more information

This inspection was carried out on 6th March 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

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

What the care home does well

Chaffinch Drive is an ordinary house and blends in with neighbourhood. It has a nice garden and is close to local amenities. The Home has had a consistent staff team for two years.

What has improved since the last inspection?

The staff team have undertaken health and safety training in first aid, the administration of medication, basic food hygiene, control of infection, fire training and had a talk on epilepsy. The registered manager is undertaking the Registered Manager`s Award with a new training provider. Some improvements have been made to the Home.

What the care home could do better:

There needs be continued improvement to the physical standard of the Home to both decoration and furnishings. The registered manager and identified members of the staff team need to complete the relevant NVQ training. The fire extinguishers must be checked and a full test of the Home`s electrical fittings` and fitments must be undertaken.

CARE HOME ADULTS 18-65 Chaffinch Residential Care Home 36 Chaffinch Drive Bury Lancs BL9 6JU Lead Inspector Julie Bodell Unannounced Inspection 6th March 2006 09:00 Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 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.V280963.R01.S.doc Version 5.1 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.V280963.R01.S.doc Version 5.1 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.V280963.R01.S.doc Version 5.1 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 October 2005 Date of last inspection Brief Description of the Service: Chaffinch House is a small 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 service residential area off Rochdale Old Road in Bury. A bus route and shops are within walking distance of the Home. The service is provided in a semi-detached house, which has been extended at ground floor level. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took place on a Monday morning over three hours. The inspector spoke with one service user, the registered manager, looked around the house and at key documents. It should be noted that a service user who had lived at the Home for many years was seriously ill at the time of this inspection and needed the attention of the registered manager, so the inspection was kept to a minimum. The inspector was informed shortly after this inspection that the service user had sadly passed away. She sends her sincere condolences to all at Chaffinch Drive. What the service does well: What has improved since the last inspection? What they could do better: There needs be continued improvement to the physical standard of the Home to both decoration and furnishings. The registered manager and identified members of the staff team need to complete the relevant NVQ training. The fire extinguishers must be checked and a full test of the Home’s electrical fittings’ and fitments must be undertaken. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 6 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.V280963.R01.S.doc Version 5.1 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.V280963.R01.S.doc Version 5.1 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): EVIDENCE: Not assessed at this inspection. Please see previous inspection report. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 Where restrictions are in place for service users, these have been formally addressed through the CPA process to ensure that there are no other options available to the service user to maintain their independence and preserve their rights. EVIDENCE: As noted in the summary at this inspection a service user was very poorly with a terminal illness. The staff team were in the process of seeking support from other agencies to help them support the service user at the Home. With little support forthcoming, the staff team are to be commended for there efforts in keeping the service user as comfortable as possible for as long as possible at Chaffinch Drive. At the last inspection, it was noted that some service users have practical support from staff members in managing their weekly cigarettes and/or money. Agreement is now documented in the service users care plan in the form of a risk assessment and is addressed as part of the service users CPA review. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: Not assessed at this inspection. Please see previous report. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 11 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): 19 20 Appropriate contact with healthcare professionals was in place. Improvements to the medication system have been made. EVIDENCE: All service users are allocated either a social worker or a CPN and have access to a psychiatrist. Service users healthcare needs appear to be properly addressed, with support provided where necessary to attend appointments. A record of all healthcare appointments is maintained. At the last inspection it was discussed that the staff team should receive epilepsy training to ensure that they can support a service user appropriately if the need arose. The staff team have had a talk on epilepsy from a CPN and the registered manager has downloaded fact sheets from the Internet for the staff team to read. The one outstanding recommendation at the last inspection, made by the CSCI pharmacist inspector, in respect of handwritten MAR entries that should be signed, independently checked and countersigned has been addressed. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Not assessed at this inspection. Please see previous report. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 13 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 Improvements to the house continue, with ongoing work to be undertaken to ensure the comfort and safety of the service users. EVIDENCE: Chaffinch House is adequately decorated and furnished. The communal parts of the home are comfortable and homely. The Home has one lounge, a dining room, with a small separate seating area, a domestic style kitchen and a garden area to the rear of the building. Privacy is facilitated by the use of service users bedrooms. Certain parts of the property are designated as nonsmoking. Some redecoration has been done since the last inspection, including the painting of a service users bedroom, ceilings and skirting boards. The new laminated floor has been laid in the lounge and dining room and some new furniture has been purchased. Work to the house is ongoing. The staff team have recently undertaken fire safety training. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 14 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): 31 35 The staff team have undertaken more health and safety training. This will help to ensure consistency for service users and promote their health and safety. EVIDENCE: Job descriptions are available for both the registered manager and the care staff. Following examination at previous inspections it was agreed with the registered provider that these documents would be reviewed, revised and updated where necessary. This has been done. All staff members at the Home must now undertake NVQ Level 2 where an equivalent qualification is not in place. Fifty percent of all care staff must now hold NVQ Level 2. Two members of staff have been identified to start the training and the registered manager is going to take the course alongside the staff members, so that she can both learn and support them. The Home has concentrated on ensuring that all staff members are trained in health and safety areas such as fire safety, first aid, basic food hygiene, and the administration of medication and adult protection. The staff team have undertaken control of infection training and dealing with challenging behaviour since the last inspection. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 15 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 42 To ensure that the service is appropriately well run and managed, the registered manager must complete NVQ Level 4 in management. EVIDENCE: The registered manager is currently undertaking NVQ Level 4, following a change in training provider. The registered manager must complete the course in both care and management. As previously stated the manager is also going to take NVQ Level 2 in care with other members of the staff team to ensure that she has the necessary underpinning knowledge. It was also felt that this would be a good team building exercise. Certificates for tests and servicing were checked. Fire extinguishers had not received a routine service due in 01/06 and the NICEIC certificate undertaken on 05.12.05 and valid for 5 years shows that it was not a 100 installation test and is therefore not acceptable. Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 16 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 2 X X X X 2 X Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 17 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 YA24 Regulation 23 Requirement That were the communal parts of the home are looking tired redecoration is undertaken. (Ongoing) That furniture that is in a poor state of repair continues to be either repaired or replaced. (Ongoing) That 50 of the staff team are qualified to NVQ Level 2. (Ongoing) That the registered manager completes NVQ Level 4 in both management and care. (Ongoing) That the fire extinguishers receive an annual check. That a full NICEIC electrical instillation test is carried out and a valid certificate produced. Timescale for action 30/06/06 2. YA24 16 30/06/06 3. 4. 5. 6. YA35 YA37 YA42 YA42 18 9 23 23 30/06/06 31/12/06 31/03/06 31/03/06 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 Good Practice Recommendations DS0000008423.V280963.R01.S.doc Version 5.1 Page 18 Chaffinch Residential Care Home Standard Chaffinch Residential Care Home DS0000008423.V280963.R01.S.doc Version 5.1 Page 19 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. 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