Inspection on 07/06/06 for Chalcraft Hall Care Home

This inspection was carried out on 7th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chalcraft Hall Care Home 02/10/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Chalcraft Hall Care Home 76 Chalcraft Lane North Bersted Bognor Regis West Sussex PO21 5TS Lead Inspector Mrs L Riddle Unannounced Inspection 7th June 2006 09:00 X10015.doc Version 1.40 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 Chalcraft Hall Care Home DS0000065445.V290693.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 Older People. 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. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chalcraft Hall Care Home Address 76 Chalcraft Lane North Bersted Bognor Regis West Sussex PO21 5TS 01243 821368 01305 889038 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) Anra Care Limited Mrs Angela Barton Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Chalcraft Hall is a residential home providing accommodation and personal care for up to twenty elderly (over the age of 65 years) persons. The home was registered to the current owners in November 2005. Application to the Commission for Social Care Inspection has been made by the registered providers, for a major variation to the home’s registration which will enable the home to include in the total number, up to eleven persons who may suffer from dementia. The application is currently being processed and a new appropriate registration certificate will be issued in due course. The registered provider is Anra Care Limited for whom the Responsible Individuals are Mr R P and Mrs A M Purusram. The registered manager in charge of the day to day running of the home is Mrs Angela Barton. The home is situated in a residential area on the outskirts of Bognor Regis close to a local shopping parade and within easy distance of the town centre with it’s train station, shops and other amenities. The detached building is set in good sized gardens consisting of paved and lawned areas. There is ample parking space to the front/side of the building. The accommodation is arranged on ground and first floors and there is a passenger lift. All rooms are for single occupancy, seventeen having full ensuite facilities and three partial. There are two lounges and a separate dining room on the ground floor. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This baseline key inspection of the home was the first inspection to take place under the current ownership. The inspection was carried out by one inspector over a period of eight and a quarter hours. Prior to the inspection the inspector reviewed information provided by the registered manager in a pre-inspection questionnaire and read correspondence and other information held on file. During the inspection the inspector spoke with residents, a visitor, a visiting nurse and staff and also had some discussion with the registered providers. Considerable discussion took place with the registered manager at various times throughout the day and a tour of the premises was undertaken. Seventeen residents were being accommodated at the time of inspection. The fee range for the home confirmed on the day of inspection is currently £380-£520 per week. What the service does well: Prospective residents and residents who already live in the home are provided with good information about the service and what they can expect to receive whilst living there. Chalcraft Hall provides cheerful, warm and homely surroundings for residents which have been and are continuing to be improved by Mr and Mrs Purusram. There is a stable staff team, several of whom are long serving members which means residents receive continuity of care and can have confidence in staff they know well. Robust recruitment procedures are followed which helps to safeguard residents. Residents are provided with a varied and healthy diet which caters for their likes, dislikes and special needs. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Ensure that a thorough pre-admission assessment is carried out in relation to every prospective resident and that wherever possible the registered manager or the person making the assessment sees the person before any decision is made to admit. Develop a comprehensive care plan for each resident based on his/her assessed needs and wherever possible involve each resident in that process. Review the care plans each month, involving the resident where possible and updating/re-writing the plans as necessary. Assess each resident in relation to any risks he/she may present and review them regularly. Dispense medications to residents directly from the containers without unnecessary handling. Be more pro-active in offering residents an alternative main meal at lunch time. Review the range and regularity of social and recreational activities currently available to residents. Ensure that potentially harmful chemicals are not left out in areas that may be unattended at times. Take precautions against the risk of hot water in wash hand basins used by residents. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 7 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. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, The home does not provide intermediate care. Residents and prospective residents have access to good information about the home and each resident receives a statement of terms and conditions. To date the process for assessing residents prior to admission has been less than robust and not consistent which could result in the home admitting someone whose needs could not be appropriately met. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: The home’s Statement of Purpose and Service User Guide was last updated in April 2006. Residents spoken with confirmed they had received copies of this document which were seen to contain their contracts/statements of terms and conditions. A copy of the Statement of Purpose was also seen to be left in the reception area, available to all. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 10 The pre-admission assessment of a resident seen in one file examined was not comprehensive and non-existent in respect of another resident admitted in recent months. The registered manager said that she had not seen one of the residents prior to admission as this person had not been able to visit the home. The manager had not in this case visited the resident either. A third file contained a Care Management assessment only. A new system is in the process of being introduced and, if completed fully, should ensure that no residents are admitted in future without a full assessment of their needs having been carried out. The manager said she is committed to improving the admissions process and to ensuring that all prospective residents are properly assessed before decisions about admission are made. She was able to provide for examination, samples of the new assessment pro-forma which will be in use as from the immediate future. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Care plans do not set out in detail the health, personal and social care needs of residents. The health care of residents is promoted and residents have access to necessary services. Personal risk assessments for residents are few and lack essential content. Medication is generally well managed but procedures for the handling/administration could be improved. Resident’s privacy and dignity is respected. The outcome for residents in relation to these standards is adequate. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: Care plans are generally very basic and do not in all cases reflect what might be going on in a resident’s life. For example, one person had developed a pressure sore and although daily notes made reference to community nurse visits, there was no mention in the care plan of this, no instruction to staff of any particular action to be taken, nothing to say whether or not any specific prevention techniques should be followed. The person’s risk assessment for skin viability had not been fully completed in February 2006 and although a Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 12 pressure sore had since developed there had been no review of this. Care plans were seen to contain such scant information as ‘needs help with washing’ and very little else. There was no evidence in the care plans of resident involvement or consultation. Residents asked were unaware of what a care plan is and had not seen one. Some resident files contained a ‘getting to know you’ questionnaire which involved questions to residents such as preferred time of rising, going to bed, evening beverages, early morning drinks, what help they would like, do they wish to self-medicate, religious wishes, hobbies and interests etc. Had these been followed up and expanded upon in the care plans they would have provided a useful tool for staff when delivering care to the individuals. Two residents spoken with said that they like to be as independent as possible and do things for themselves which is encouraged. Risk assessments were seen to lack detail and did not include the action needed in order to minimise the identified risk. One resident had suffered a fall which resulted in a hospital attendance. However the ‘Slips, Trips and Falls’ (Review to be carried out after a fall) had not been completed. Fall risk assessments had no ‘key’ to score what risk a resident might be assessed as eg. Low, medium, high. There was no risk assessment in relation to a resident who smokes and how this is managed. The registered manager was able to produce for examination, a sample of a new care plan pro-forma which she intends to implement for all residents as a matter of priority. If completed correctly and in consultation with residents these should provide much more detail as to the needs and support required. The registered manager also stated that a key-worker system is to be introduced. Daily notes and records of GP visits, nurse visits, hospital and other appointments showed that the healthcare of residents is promoted and catered for and residents expressed satisfaction with the arrangements. Comments included “I see the chiropodist regularly, the optician if needed and staff call my doctor out if I’m not well”. One resident was expecting a visit from the diabetic nurse advisor later that day. Another resident said that she was seeing an audiologist in the near future to see if her hearing could be improved. When a resident was observed being transferred from a wheelchair to a dining chair staff were seen to explain what was happening and what they needed the resident to do to assist before the move took place. They were seen to use good lifting techniques. Staff were observed to chat with residents as they went about their work. One resident who likes to remain in her room said that she enjoys it when staff pop in and out to chat and see if she is alright. She said that she never feels lonely because she sees plenty of people. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 13 Medication was seen to be stored in a locked trolley, kept in a recessed area of the dining room. Policies and procedures are in place. Medication administration record sheets were completed up to date. The manager confirmed that the named staff who handle and dispense medications have had in-house training and further training in the safe handling of medication is on the training plan for this year as was seen. A cream prescribed for one resident was found to be in use in another resident’s room. A member of staff taking lunch time medication to a resident was seen to tip the tablets into her own hand from a medicine cup before giving it to the resident. The dosset box was not taken directly to the resident’s room which meant that the tablets had been handled twice before reaching the resident. No residents had control of their own medications and forms were seen to be signed in their files to say that they did not want to do so. However, consideration should be given to the way more able residents might be actively encouraged to take (or keep) control of their medications, subject to any outcome of a risk assessment. Residents spoken with confirmed that staff speak to them respectfully and this was observed during the inspection. Staff were observed to knock on doors and wait before entering. Residents said that treatments and consultations take place in private. They can have keys to their rooms if they wish. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above 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 A programme of activities is in place but could be improved upon in terms of regularity and content to provide a more full and stimulating lifestyle for residents. Visitors are made welcome and residents can maintain links with the community. The home’s policies, procedures and quality assurance systems ensure that residents are protected from financial abuse. Residents receive a varied and balanced diet but are not always actively offered an alternative to the main midday meal. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: An outside organiser provides a fortnightly exercise class for residents who wish to attend and a record of attendance at this was available. Another outside organiser runs a gardening club also on a fortnightly basis and a mobile library visits two-weekly. Staff said that they organise games such as Bingo, snakes and ladders, scrabble when they have time. There are also weekly outings in the home’s own transport. There is currently no forum for residents to contribute their views and wishes in relation to activities and Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 15 routines in the home, although staff said that residents do say if there is somewhere in particular they want to go for an outing. This was discussed with the manager. Care plans currently contain little or no information about individual resident’s interests or wishes in relation to their social care needs. These need to be in place in order that the service provided can be as individual as possible and use its’ staff and resources effectively. One resident said that she would like there to be more activities. Another said that she gets bored just sitting, she used to like to read but her eyesight is now too poor. She said that she would like to go out more in her wheelchair but had not asked staff because she perceived them as not having enough time. Visiting arrangements are included in the Information provided for residents and others. Residents said that they can have visitors when they wish and see them in their rooms or in one of the communal areas if preferred. Comments included “visitors can come at any time” and “we can have visitors when we like”. A visitor spoken with confirmed that she is able to visit daily and always made welcome. Residents can manage their own finances if they wish and are able to do so. Others may have family or representatives to do so on their behalf. The registered manager confirmed that the home does not handle the personal monies of residents. Each resident has a digital wall safe in his/her bedroom to safely store money and valuables. Meals are at set times but can be flexible if needed. The main midday and early evening meals were observed during the inspection. Most residents attended the dining room for their main meal although a small number, by choice, were seen to be served in their rooms. Fewer residents attended the dining room for the evening meal but again this was their choice. A menu was not displayed for residents but the manager said that this was an oversight because the usual cook was off sick that day. Menus for a four weekly period were provided with the pre-inspection questionnaire. They showed that residents receive a varied and well balance diet, as was confirmed by residents generally. It was evident that residents can choose more or less what they like for their evening meal. At the time of inspection this was seen to include various salads, such as ham, cheese or pork pies, eggs cooked in various ways, sandwiches, soup and toast. The lunch time main meal does not offer specific alternatives although it was evident that residents could ask for something else if they felt confident to do this. One was seen to request soup as a lighter alternative. One said that she did not know if an alternative would be provided, she thought it might be but had never asked. The home should be more pro-active in letting residents know what is available as a daily alternative/s. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 An appropriate and clear complaints procedure is in place and has been made available to residents. Procedures are in place and understood by staff, in order to keep residents safe. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: The Statement of Purpose and Service User Guide, of which all residents have a copy, contain details of the procedure to be followed should they or others wish to make a complaint. A copy is also displayed in the home. Residents spoken with were aware of the procedure and said that they felt comfortable about complaining if the need arose or sharing concerns with the management and staff. Comments included “I complain when I need to and it’s usually put right”. An anonymous complaint made to the Commission in January 2006 was passed on to the providers for investigation. The Commission was advised of their investigation and the outcome was that the allegations were unfounded. The manager was reminded that records of any complaints and investigations should be kept in the home available for inspection. The home was seen to have a copy of the West Sussex procedures for Adult Protection and a comprehensive procedure for the home which is consistent with these. A ‘whistle blowing’ policy is also in place and staff spoken with Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 17 indicated their awareness of their responsibilities in relation to the protection of vulnerable adults. Staff had received some in-house training in relation to this and further training was seen to be on the programme for this year. The home’s recruitment procedures also assist in protecting residents. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23, 24, 25, 26 Residents live in a generally safe and well maintained environment, and the home is clean, pleasant and hygienic. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: A programme of maintenance and renewal of the fabric and decoration of the premises has commenced and will be on-going. A number of improvements have already been made by the providers including for example the installation of eight new double glazed windows, the fitting of a new patio door to the lounge, the updating of electrical wiring, the installation of electronic alarms to all exits for security of residents and the redecoration and refurbishment of six bedrooms. A new hoist has been provided and the home has access to chair weighing scales (shared with another home also owned by the providers). There are no shared rooms and all rooms seen were homely with residents own possessions much in evidence Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 19 One bedroom viewed was vacant and in need of redecoration /refurbishment. The bed was still made up in this room with obviously slept-in bedding and did not look inviting for any prospective resident to view. The shared areas provide a choice of communal space and are comfortably furnished, light and cheerful. Some residents were seen to sit together in various areas of the lounge and dining room, seating being arranged in a noninstitutional way where they can sit away from the television if they do not wish to watch it. A smaller separate lounge provides a quiet area if this is preferred. There is a choice of bathing facilities including assisted baths. Radiators are fitted with covers for safety. The hot water in a wash hand basin was felt to be excessively hot, and there were no notices to warn of possible hot water. Baths are fitted with thermostatic valves to control temperatures but hand basins are not. This may present more of a hazard if confused residents are accommodated. The home has an infection control policy to be followed by staff. All areas of the home were clean and fresh. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Sufficient staff are employed to meet the needs of current residents and the providers are committed to having a well trained staff team. Thorough recruitment procedures are followed. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: Duty rotas seen indicated that there are sufficient staff employed to meet the needs of current residents although these may need to be reviewed if the dependency levels of residents increases significantly. The providers have improved the night time cover by providing two awake staff each night. A deputy manager has also been appointed whose hours like those of the manager, are supernumerary to the rota most of the time. The home has a training programme planned for the year which was seen to include updates in topics such as moving and handling, fire safety, food hygiene, safe handling of medication, protection of vulnerable adults, confidentiality and care planning. One member of staff is currently undertaking National Vocational Training at level 3 and three are doing level 2. As part of their medium term plans the providers are committed to increasing the percentage of staff with level 2 to at least 75.25 . Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 21 As a matter of priority there will be a need for staff to receive appropriate training in preparation for caring for people with dementia. Four staff files were examined and found to contain the necessary documentation to show that the home is adhering to sound recruitment procedures which involve at least two references being obtained and Criminal Records Bureau and Protection of Vulnerable Adults checks. Records are maintained if there are disciplinary actions concerning any staff. The manager was able to produce a sample of a new application form which has been brought into use and which will be used as from the immediate future. This was seen to be very comprehensive. Staff confirmed that they had each been provided with staff handbooks and contracts of employment. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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, 33, 35, 38 The home employs a suitably qualified and experienced registered manager. A quality assurance system has been implemented which should ensure that the home is run in the best interests of the residents. Residents financial interests are safeguarded. Some improvements need to be made to ensure that the health and safety of residents is promoted and protected. The outcome for residents in relation to these standards is good. This judgement has been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. EVIDENCE: The registered manager has achieved the National Vocational Qualification at level 4 and the Registered managers Award. She was in post as registered manager prior to the current ownership. She is aware of the National Minimum Standards and, with the support of the registered providers is working towards meeting all of these in full. Records are generally up to date Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 23 but care plans, risk assessments and pre-admission assessments need a considerable amount of work to ensure that resident’s needs are fully identified, planned for and met. The manager is aware of the areas that need improvement. A visiting professional spoken with during the inspection expressed some concerns about a previous visit she had made to the home, had rung the door bell to no avail, finally walked in and been unable to find any staff. She finally located them outside at the rear of the home having a cigarette. Whilst staff are entitled to breaks, the home and residents should not at any time be left unattended in the interests of safety, security and good practice. It is a managerial responsibility to ensure that staff are deployed in such a way that there is always cover within the home. Currently there is no official forum to enable residents to contribute to the way in which the home is run and the manager said that she will give this matter some consideration. Staff spoken with said that the manager is always very accessible and provides clear direction and support. Several members of staff have worked in the home for some years making the team a generally stable one. Staff presented as being enthusiastic about their work, and said they found it a pleasant place in which to work. Several staff had come in to the home during their off duty to attend a meeting with the providers and following that, a brief meeting with the manager. Staff knew about their responsibilities in relation to protecting residents from all forms of abuse and bad practice. They confirmed that staff meetings are held on a fairly regular basis usually and they receive supervision from the manager. The timetable and formats for supervision were seen during the inspection. The providers have implemented an Annual Development plan for quality monitoring which identifies improvements made so far and the benefits these have had for residents and staff. Future plans include their short, medium and long term goals for the home. The registered manager has been closely involved in the planning and will, on a day to day basis, be responsible for monitoring the quality of care provided. The providers visit the home on a weekly basis to provide support and direction for the manager. They are now completing a full monthly report on the conduct of the home in accordance with their legal responsibilities and as part of the quality monitoring. The views and experiences of residents, relatives and others will be sought later this year through questionnaires as part of the home’s commitment to quality assurance. A few months after they took over the home, the providers also held an open day when relatives, friends, care managers and other professionals involved with the home were invited. Their views and opinions about the home were sought and have and will be acted upon. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 24 As previously mentioned, the home does not handle resident’s financial affairs. If any expenditure has to be made on behalf of any residents for services such as hairdressing or chiropody or for personal items they may want or need, this is paid by the home, records maintained by the manager and the resident’s representatives are sent an account periodically. The home has a comprehensive health and safety policy and has commissioned an outside company to provide full 24 hour health and safety cover for the home. A risk assessment of the premises has been undertaken as part of this. Staff have received or will be receiving appropriate training in health and safety topics. Some cleaning products were seen to be left out in the kitchen although this was unattended at the time. These included such items as thick bleach, kitchen cleaner, oven cleaner and pipe unblocking chemical. The ground floor windows are not fitted with restrictors and it has been agreed that these will be fitted as part of the conditions of the variation to the registration being granted. Similarly it has been agreed that the gardens will be made secure before any residents with dementia are admitted. The hot water in the hand-basin of the first floor bathroom was excessively hot to the touch. Records showed that the testing of fire equipment was up to date and staff had received in-house training in fire safety. Accidents had been appropriately recorded and reported where necessary. Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 OP3 Regulation 14(1)(2) Requirement The registered person shall not provide accommodation to a resident unless the needs of the resident have been assessed by a suitably qualified or suitably trained person. The registered person has obtained a copy of the assessment. The registered person shall after consultation with the resident or a representative of his, prepare a written care plan as to how the resident’s needs in respect of his health and welfare are to be met. The registered person shall keep it under review, make it available to the resident, consult with the resident where possible before revising the plan, notify the resident of any such revision. The registered person shall ensure that all unnecessary risks to the health or safety of residents are identified and so far as is possible eliminated. (Control the temperature of hot water within safe limits and look to a long term solution to this) DS0000065445.V290693.R01.S.doc Timescale for action 08/06/06 2 OP7 15 (1)(2) 07/09/06 3 OP38 13 (4)(c ) 08/06/06 Chalcraft Hall Care Home Version 5.1 Page 27 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 Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Chalcraft Hall Care Home DS0000065445.V290693.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!