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Inspection on 06/10/05 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 October 2005.

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

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

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.

What has improved since the last inspection?

The Home has had a consistent staff team for about a year. The staff team have undertaken health and safety training in first aid, the administration of medication, basic food hygiene and more training is planned. Improvements have been made in respect of the administration of medication and fire safety. The registered manager is undertaking the Registered Manager`s Award. Some improvements have been made to the Home. Some service users are now engaged in more meaningful activities outside the Home.

What the care home could do better:

NVQ level 2 training in care needs to be undertaken by the staff team. Outstanding health and safety training must be completed. Any restrictions being undertaken by the Home need to be discussed at the service users CPA.

CARE HOME ADULTS 18-65 Chaffinch Residential Care Home 36 Chaffinch Drive Bury Lancs BL9 6JU Lead Inspector Julie Bodell Unannounced Inspection 09:15 6 October 2005 th Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 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.V249793.R01.S.doc Version 5.0 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.V249793.R01.S.doc Version 5.0 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.V249793.R01.S.doc Version 5.0 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. 8th February 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.V249793.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. It took on a Thursday morning over four hours. The inspector spoke with one service user, the registered manager and briefly the registered provider, looked around the house and at key documents. The main focus of this inspection was to look at issues raised at the previous announced inspection. What the service does well: What has improved since the last inspection? What they could do better: NVQ level 2 training in care needs to be undertaken by the staff team. Outstanding health and safety training must be completed. Any restrictions being undertaken by the Home need to be discussed at the service users CPA. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 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.V249793.R01.S.doc Version 5.0 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.V249793.R01.S.doc Version 5.0 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): 234 There is a settled group of service users living at the Home and no concerns were raised about the Home’s ability to meet their needs. EVIDENCE: There have been no new service users admitted since the last inspection. Assessments were in place on the service user files examined. The inspector had no major concerns at the Home’s ability to meet the behavioural management needs of service users. The registered manager during conversation demonstrated a good understanding of the needs of the service users and what action to take should there be deterioration in the service users mental health. The registered manager said that prospective service users are able to visit the Home, have tea and meet with service users and the staff members prior to admission. There is also a three-month “settling in” period within the contractual arrangements. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 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): 79 Service users have very independent lifestyles and this is encouraged. Where restrictions are in place for service users, these must be formally addressed through the CPA process. EVIDENCE: Service users through discussion and observation do appear to exercise a fair degree of autonomy over their day-to-day lives. Some service users have practical support from staff members in managing their weekly cigarettes and/or money. Where restrictions are in place, agreement should be documented in the service users care plan in the form of a risk assessment. This should then be brought to the attention of a third party i.e. social worker or CPN during formal review process. This will ensure that the service user agrees to the restriction and that all other areas have been explored to prevent that risk assessment, so as to uphold the service users human rights and acknowledge any adult protection issues. Some restrictions can now be seen on the service users CPA. Following discussion with the registered manager it was agreed that the outstanding areas would be raised at the service user’s CPA review. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 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): 12 13 14 15 16 17 The inspector notes continued improvements for service users in this area, which is in part due to improved staffing arrangements at the Home. EVIDENCE: Four of the five service users have busy lifestyles. One service user has started a fulltime college course in catering. This is a major commitment on the part of the service user and is going well and the staff team are very supportive of the service user. A second service user attends a day centre, a weight watchers programme and has started guitar lessons. Other service users visit family members regularly. One service user is moving onto semi-independence project in the near future. The registered provider was reminded of the implications this would have in respect of the registration certificate and future admissions to the Home. Four service users went away for a long weekend in a caravan with two staff members to Blackpool and judging by the photographs everyone had a great time. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 11 Service users are supported to maintain links with their family and friends, and are able to have friends and visitors to the Home. Menus are maintained. The menu is based around the likes and dislikes of the service users. The registered manager is aware of healthy eating and confirmed that the budget for food was adequate at this time. On the day of the inspection it was cereal and toast for breakfast, ravioli for lunch and Shepherd’s Pie for tea. Apples from trees in the back garden have been used to make pies and the service user who is at college had been bringing back the food they had made for the other service users to try. The Home has started to get involved in recycling. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 12 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 20 A good relationship between service users and the staff team prevails and appropriate contact with healthcare professionals was in place. Improvements to the medication system have been made. EVIDENCE: The relationships between staff members and service users appeared warm, caring and friendly. The registered manager was seen to treat service users with courtesy and demonstrated a good understanding of their likes, dislikes and preferred routines. 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. Concerns about a service users weight loss have been addressed. Following a request from the inspector at the last inspection a visit by the CSCI pharmacist inspector has been undertaken. One requirement and six recommendations where made and all but one recommendation in respect of handwritten MAR entries should be signed, independently checked and countersigned. 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. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 13 Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 14 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 23 The complaints procedure has been updated and the staff team are to attend adult protection training, which will help to ensure the protection of service users. EVIDENCE: There have been no complaints in respect of this service since the last inspection. The complaints procedure has been amended to reflect the change from the National Care Standards Commission to the Commission for Social Care inspection. Since the last inspection the registered manager has obtained a copy of the Local Authority Adult Protection and arrangements for the staff team to undertake adult protection are in place for 27th October 2005. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 15 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 30 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. New beds and mattresses have been bought for two service users. Work to the house is ongoing. The floor to the lounge and dining room needs replacing, as does some furniture. There have been improvements to the garden area to the rear of the home, which is accessible to the service users. The registered manager said previously that she would like to involve the service users in gardening projects this year and that plants would be made available by the responsible Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 16 individual. However, none of the service users have been keen to get involved in gardening. A fire officer carried out a fire safety visit during the last inspection and a number of recommendations were made. The fire officer conducted a return visit to the Home approximately five weeks later to check that necessary action had been taken. Fire records checks were examined. Weekly for the alarm system, emergency lighting and means of escape are carried out. The staff team need to undertake fire safety training and are waiting confirmation from the training company for a date. Service users bedrooms are appropriately equipped. In the main bedrooms achieve an adequate standard of decoration and furnishing. Service users have personalised their bedrooms to varying degrees and all bedrooms can be locked with individual heating controls provided. A payphone for service users is available at the foot of the stairs or the office telephone can be used. The Home has one bathroom, with an over bath shower, a walk in shower and two toilets, which is sufficient to meet the standard. The communal parts of the Home were clean and tidy on the day of this inspection. The service users are responsible for the cleaning and tidying of their bedrooms and some need encouragement and assistance with this task. A cleaner has now been employed for eight hours a week and an improvement in standards was noted. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 17 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 32 33 35 36 The inspector is pleased to report that the staff team remains stable and that they have undertaken a significant amount of 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 the last inspection it was agreed that these documents would be reviewed and revised and updated where necessary. This has been done, but remains a very practical task orientated document with no reference to the service users health needs. Further work is needed and this was discussed with the registered provider. The registered provider is an experienced psychiatric nurse and retired nurse manager. The registered manager is currently undertaking NVQ Level 4 in management through Bolton College. There are no trainees at the Home or staff under the age of eighteen. Staff members who had started to undertake NVQ Level 2 have now left the Home. A qualified nurse is currently working as a casual member of staff. A CPN covers on an on-call basis in the absence of the provider. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 18 As a Home registered under the Registered Homes Act 1984 staffing levels must go below the minimum required prior to the 31st March 2002. There are four core members of staff with three other staff members available to provide cover as and when necessary, to ensure consistency for the service users. All staff members at the Home must now undertake NVQ Level 2 were an equivalent qualification is not in place. Fifty percent of all care staff must hold NVQ Level 2 by the end of 2005. 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. There has been a significant improvement in this area since the last inspection. The registered manager is undertaking formal supervision with staff members. The frequency of supervision has been increased to an annual appraisal and five supervision sessions throughout the year. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 19 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 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 through Bolton College. The registered manager must complete the course in both care and management. Following discussion with the registered manager it was decided that she would complete the NVQ Level 4 in management and start NVQ Level 2 in care with other members of the staff team to ensure that she has the necessary underpinning knowledge for NVQ Levels 3 and 4 in care. It was also felt that this would be a good team building exercise. Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chaffinch Residential Care Home Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X X X DS0000008423.V249793.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement That were restrictions in respect of service users are in place, that a risk assessment is conducted that includes the service users agreement and forms part of the formal review process. That handwritten MAR entries should be signed, independently checked and countersigned. That the staff team should receive epilepsy training. That the communal parts of the home are looking tired in parts continue to be redecorated. That furniture that is in a poor state of repair continues to be either repaired or replaced. That the staff team receive fire safety training. That job descriptions are reviewed and revised and amended accordingly. That all staff members receive health and safety training, as identified in this report. That 50 of the staff team undertake NVQ Level 2 by the end of 2005. DS0000008423.V249793.R01.S.doc Timescale for action 1 13 YA9 31/12/05 2 3 13 13 YA20 YA20 31/10/05 31/12/05 4 23 YA24 31/12/05 5 6 7 8 9 16 23 19 13 18 YA24 YA24 YA31 YA35 YA35 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 Page 22 Chaffinch Residential Care Home Version 5.0 10 9 YA37 That the registered manager completes NVQ Level 4 in management and care. 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 Standard Good Practice Recommendations Chaffinch Residential Care Home DS0000008423.V249793.R01.S.doc Version 5.0 Page 23 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.V249793.R01.S.doc Version 5.0 Page 24 - 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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