Inspection on 20/06/06 for Chaldon Rise

This inspection was carried out on 20th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chaldon Rise 06/11/07

Chaldon Rise 14/03/07

Chaldon Rise 09/01/06

Chaldon Rise 13/09/05

Chaldon Rise 15/11/04

Chaldon Rise 15/06/04

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Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

Dovedale Court

1 Marten Road

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

CARE HOMES FOR OLDER PEOPLE Chaldon Rise Rockshaw Road Merstham Surrey RH1 3DE Lead Inspector Lesley Garrett Key Unannounced Inspection 20th June 2006 08:00 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 Chaldon Rise DS0000013307.V316943.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 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. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaldon Rise Address Rockshaw Road Merstham Surrey RH1 3DE 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) 01737 642281 01883 340498 Care Unlimited Mrs Carmelita Paat Shamtally To be confirmed Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Learning registration, with number disability (10), Mental disorder, excluding of places learning disability or dementia (5) Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Up to 10 beds may be used for people with a Learning Disability above the age of 40 years Up to 5 beds may be used for the care of mentally ill residents between ages of 21 and 60 years Up to 2 beds may be used for Respite Care The age/age range of the persons to be accommodated within the category DE(E) is over 65 years. The gender of those accommodated will be: MALE AND FEMALE Date of last inspection 9th January 2006 Brief Description of the Service: Chaldon Rise is one of three homes owned by Care Unlimited, and is a country house, which stands in its own five-acre grounds that surround the home. The house is situated on the outskirts of Merstham village. The home is registered to offer nursing care for up to 34 older people with Dementia. The home can also care for up to 10 residents with learning disability and 5 with a mental disorder. Accommodation is arranged over three floors accessible by a lift. Bedrooms are mainly single with en-suite toilets and some have bathrooms. The home offers car-parking facilities for several vehicles. The prices of the rooms are from £630 - £834. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over eleven hours and stated at 0800 finishing at 1900. Lesley Garrett, Lead Inspector for the service carried out the inspection and the deputy manager, represented the establishment. A full tour of the premises took place. The inspector saw most of the residents however verbal feedback from the service users was limited to a small sample as a result of communication problems for some who were particularly frail. A pre-inspection questionnaire was used as information for the inspection and service user survey forms (comment cards) were sent to the service and some were available for the purpose of writing this report. One returned comment card said the best thing about living at the home was being well cared for, well fed and made safe by caring staff. Policies and procedures were also sampled and the inspector also looked at the individual plans of care and staff employment folders. One matter has recently been referred under the local authorities multi agency procedures for safeguarding adults. The inspector would like to thank the service users, staff and deputy manager at Chaldon Rise for their time, assistance and hospitality during this inspection. What the service does well: The inspector had received some ‘comment cards’ from the relatives and these all contained positive comments about the staff and facilities. On the day of inspection a relative spoke with the inspector and told her she visited her mother regularly. It was evident through feedback from a relative that complaints were listened to and acted upon. The relative stated, “I know how to make a complaint but I have not got one and prefer to sort things out face to face”. “They have a good staff team”. The home have a good standard of written care plans and risk assessments in place which addressed a wide variety and range of service users’ needs. The care plans demonstrated that the staff had a good understanding of the service users’ needs. The home provided a variety of social activities for service users. An Activities Coordinator was employed by the service. The provider stated that social events were provided throughout the year and are well attended by service users, relatives and friends. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 6 Menus were varied and service users were able to choose from a number of options for their meals. The meals provided were observed to be well presented, nutritious and well balanced. The standard of hygiene in the home was good and those areas viewed were observed to be clean and tidy, with no malodour. Staff mandatory training was being provided, including moving and handling, safeguarding adults, food hygiene and first aid. What has improved since the last inspection? What they could do better: The inspector arrived at 0800 and found that half of the service users were up and dressed and starting breakfast. The deputy manager stated that it is usual for the night staff to get the service users up, as they are awake. This was not evidenced in the care plans that the inspector sampled. While the service had a good standard of care planning in place, the individual care plans need to be reviewed every month. Care plans should be signed by the service users and/or their relative or representative to evidence consultation and should include areas such as the need to assist those service users who wake early. Several requirements were made and can be seen in more detail at the end of the report. The management and staff need to receive training regarding protecting adults from abuse and need to ensure that all potential adult abuse matters are referred as required under the local authority procedures. An immediate requirement was made in respect of this area and the deputy manager took action on the day of the site visit. The management and staff would benefit from completing the local authority’s Safeguarding Adults training to increase awareness of adult protection matters. It was also an immediate requirement that all staff employed at the home has the relevant documentation in place before starting work to ensure service users are protected. The post of home manager was vacant at the time of the site visit. The service has not had a permanent manager since January 2006. A requirement was made as a result. There were three medications, which were out of stock for two service users resulting in them not receiving these medications on the day of the inspection. This was potentially putting service users health and welfare at risk. The Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 7 pharmacist issued a letter to immediately address this issue. The provider stated that one medication was not available from the pharmacy and had been requested. Following the site visit, the provider reported that a new system of medication audit and check sheet had been introduced. The home must include details of the Commission in their complaints policy and also they must keep a record of all complaints, to evidence that all concerns are listened to and acted upon. 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. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 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 Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users that move into the home have their needs assessed by someone competent to do so and are then assured that their needs would be met. The home has no intermediate care beds. EVIDENCE: The deputy manager told the inspector that all admissions to the home have a pre-admission assessment. Either herself or the provider would carry these out. Evidence of these assessments was seen in the individual folders and care plans are then generated from the assessment. The home does not provide intermediate care beds. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service users individual plans of care are comprehensive and demonstrate that their health and personal care needs are met. A specialist pharmacist inspection was undertaken on 3rd July 2006. The home could not demonstrate that medication was administered to all service users as prescribed for them by their doctor. This could put at risk the health and well being of the people using the service. The privacy and dignity of all service users has improved since the last inspection. EVIDENCE: The inspector sampled some individual service user folders and found them to contain a good variety of care plans and risk assessments. These plans demonstrated that the staff had a good understanding of the service users needs and was clearly written. The relatives or representatives did not sign these plans and this will be a requirement at the end of the report as this was Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 11 a recommendation following the last inspection. In the event that the service user, their relative or representative is unable to sign their care plan the home should indicate this and document that the home is unable to obtain a signature. The local general practioner visited the home every week and the deputy manager stated that they were a good support. There was evidence that reviews of the service users are held every six months and medication reviews take place also. The deputy manager stated that the home has a chiropodist that visits every six weeks and the dietician and speech and language therapist also visit regularly. Other visiting professionals are the optician and a palliative care nurse if necessary. A specialist pharmacist inspection was undertaken on 3rd July 2006. This involved looking at the medication handling procedures, watching some medications being given to service users, looking at medication storage and records. Medication procedures were available to the staff for reference. However they described some practices and systems no longer used in the home. This may lead to inconsistent practice by the nurses. The standard of record keeping was adequate. Clear records were kept of all medicines coming into the home and of any medicines disposed of. Records were kept when medication was given to service users. However there were some entries left blank on the administration records charts when medication should have been given. Also two doses of medication were still in the blister packs in the home but the records were signed, indicating that they had been given. This puts into question the reliability of other records. The records showed that two medicines were not available in the home and that a third was being borrowed from another service users supply. The Medicines Act 1968 clearly defines that medicines must only be administered to the person for whom they have been prescribed, labelled and supplied. If medication is not available in the home the health and welfare of service users could be put at risk. Medication was stored securely for the protection of the service users. Whilst the medical room was very small and did not provide the staff with a clear working space the medication cupboards and trolleys were clean and orderly with the keys being held by the registered nurses. There was a medication refrigerator but the daily temperature monitoring records showed this fridge to be operating above the correct temperature and Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 12 no action had been taken to correct this. This could be damaging to the medicines, which require being stored at a low temperature. A number of service users were prescribed sedative medicines to be given to them only when needed. Of those tracked during the inspection none had a care plan guiding staff on when this medicine should be given. This was putting these service users at risk by not having these medicines given in a clear and consistent way, which could have an adverse effect on their welfare. Part of a drug round was observed during the inspection. The system in the home is that one nurse prepares the dose, referring to the chart, then gives the medication on an unmarked tray to a second nurse or carer to administer, unobserved by the first nurse whose signature appears on the chart. This is not considered to be good nursing practice as the nurse who is accountable for the administration does not perform nor always observe the whole task. Following the homes last inspection in January 2006 the inspector made a requirement that the residents privacy and dignity been improved by covering the window to their bedrooms. This has now been completed on a temporary basis and the home is now waiting for the blinds to be fitted to the windows in the doors. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are varied and tailored to the serviced users needs. Contact with families, friends and the community are encouraged and supported. Service users are encouraged by the staff to make choices in their daily lives. There is a varied menu and special diets are catered for and service users were seen to be given choice at mealtimes. EVIDENCE: The home has a new activities organiser who is currently registered with a local college to do her national vocational qualification level 2 in activities. The inspector spoke with the organiser and she told her that she has a varied programme of activities, and the inspector saw this programme, which included time for individual one to one activities with service users. The organiser talks with service users and their families to see the kind of things that they would like to participate in. The home has its own minibus and trips in this have been arranged. During the week of the inspection the home has its summer fete organised and local Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 14 neighbours have been invited along with families and friends. On the day of inspection the local vicar was in the home and spoke with the inspector. She told her she visits regularly to give communion for those that wish and will often sing hymns with them. The inspector witnessed service users being given choice during the inspection. At breakfast there was a good variety and service users could select what they wanted. Due to their mental frailty it was difficult for the inspector to ask questions of the service users but observations were made used throughout this inspection. It was noted that some service users were selecting where to sit in the lounge and also what they would like to wear. Choice is also given with activities and what they would like to participate in and this is documented. The home has two chefs and between them they cover the home everyday. The inspector spoke with both chefs and saw the kitchen. On the day of inspection the kitchen was very clean and tidy and one chef was preparing the meatloaf for lunch. Fridge temperatures were taken twice a day and the inspector saw the recordings. The chefs work on a four week rota for the menus and the head chef told the inspector that there is always a cooked breakfast available every other day but if any service user wants something cooked on the other days it is made available. There are two other meals during the day and afternoon tea with cake, drinks and snacks are available through the night. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for receiving and responding to complaints were adequate. The management and staff need to improve their awareness of safeguarding adults in order to ensure service users’ welfare is promoted and protected. EVIDENCE: The home has a complaints policy, which is displayed in reception and available to all service users and their families or representatives on admission. The policy does not contain contact details for the Commission and this has been made a requirement at the end of the report. The deputy manager said there has only been one verbal complaint since January when the manager left. The home has a complaints log available but the deputy was unsure where previous complaints records were kept. On the day of inspection the inspector was told of an incident that had been dealt with under the homes disciplinary procedures. This should have been referred to the local authority under their safeguarding adults procedures. It was referred on the day of the visit and a planning meeting has taken place so the relevant agencies are now aware. The deputy manager told the inspector that the provider had just appointed two new managers for quality and human resources but neither knew the procedures for safeguarding adults. The deputy manager stated that staff had training in safeguarding adults from the homes Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 16 training manager but they had not accessed the local authority multi agency training and this will be a requirement at the end of the report. The deputy, who has been acting manager since January 2006 was also unsure of the procedures. The home did not have the February 2005 copy of Surrey Multi Agency Protecting Adults procedures and this too will be a requirement at the end of the report. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was clean with no offensive odours, however refurbishment and redecoration is needed in some areas to improve the presentation of the environment for service users. EVIDENCE: The home has a full time maintenance person and rooms are decorated as needed and when they have been vacated. Some of the bedrooms were observed to be in need of refurbishment in order to improve their presentation and attractiveness for service users. On the ground floor some of the rooms are small and dark, as light is not entering adequately. Those rooms, which were observed to be smaller in size would benefit from a review of the lighting and decoration. There was no routine programme of maintenance in place and therefore this will be a requirement at the end of the report. The home still has a number of divan beds and these will need to be replaced on a regular basis as the needs Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 18 of the service users are increasing and the beds are no longer suitable for providing care. The inspector met the laundry assistant who described the routine for the laundry and she had a good knowledge of infection control and the sluicing procedures for the washing machine. The room was small but was clean and tidy and all clothes when washed was placed in the individual baskets and then delivered back to their rooms. There were no offensive odours in the home. The inspector did not view the upper floor of the home during this site visit. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff rota does not demonstrate that the skill mix is adequate to meet the service users needs. Service users are not fully protected by the home’s recruitment policy. There is adequate training in the home, which is undertaken on a regular basis, however the numbers of carers who have the national vocational qualification (NVQ) falls short of the 50 requirement. EVIDENCE: The inspector was sent a sample of the staff rota with the pre-inspection questionnaire. Following the inspection the inspector asked for details of the registered nurses qualifications. While qualified nurses were deployed in the home, it was noted that some of the shifts do not have a level 1 nurse or some one with suitable qualifications in charge for example they have the mental health qualification in place of Registered nurse or registered mental nurse and the inspector asked for confirmation of the staff list from the home and this will be a requirement at the end of the report. The deputy manager told the inspector that the home does not have 50 of their staff with NVQ certificate. The deputy manager did, however, tell the Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 20 inspector that there is ongoing training in the home and some carers were now attending the course. The inspector sampled some employment folders and found that there were no explanations for any gaps in their employment history. On the day of the site visit a staff file sampled did not evidence an up to date (CRB) criminal record bureau check completed for a member of staff. This has since been confirmed as having been completed by the home in writing to the Commission. The deputy manager stated that the home has a training plan and it was evident that training has taken place and further planned. All inductions for new staff are linked to the ‘skills for care’, which is a recognised national training programme. All mandatory training has taken place for example, food hygiene, first aid, manual handling and safeguarding adults. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has had no manager since January 2006 therefore service users have not had the benefit of consistent management. This outcome area has been assessed as adequate in view of there continuing to be no permanent and registered manager in place. The financial interests of the service users are safeguarded and the health and safety of all service users are promoted and protected. EVIDENCE: The home has been without a manager since January 2006. At the time of the last inspection in January the manager informed the inspector, that systems were in place to replace her and the advertisements had gone out. However there is still no permanent manager. The inspector was again told during this Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 22 visit that the post had been advertised. This will now be a requirement for the home to appoint a manager as soon a possible and for that person to then be registered with the Commission. The newly appointed quality manager stated that every year anonymous surveys are sent to the relatives or representatives of the service users to gauge the level of satisfaction within the service. Findings are discussed with the relatives or representatives and any problems acted upon. Other visiting professionals are also asked to complete a form Relatives or representatives are also invited to a quarterly meetings which is minuted and all relatives have a copy sent to them. Monthly audits by the responsible individual are completed and sent to the commission. Policies and procedures have not been updated but the home has a new quality assurance manager who stated that he will be reviewing all policies and they will be updated every six months . This will be a requirement at the end of the report. The administrator handles the sundries account for the service users that have no relatives. Records are kept and all transactions are accounted for. All monies are kept seperately and they are not pooled. No service user handles their own money. Reports are sent to the relevent care managers to inform them of their accounts for the service users they are responsible for. All the necessary health and safety certificates are in place and all the checks necessary have taken place and this was evidenced in the pre-inspection questionnaire sent to the inspector. Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 23 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X 2 X 2 X X 2 Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 24 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. 2. Standard OP7 OP7 Regulation 15 15 Requirement The registered person must ensure that all individual plans of care are reviewed monthly. The registered person to ensure that all individual plans of care are discussed with the service user, relative or representative and signed. This was a recommendation in the last inspection report dated 09/06/06. The policies and procedures relating to the handling of medication must be reviewed and updated to reflect the current practices in the home. A thermometer must be kept in the medication refrigerator and daily temperature records made to ensure that it is operating within the correct range of 2 to 8 degrees centigrade and that the quality of the medication held in it can be assured. Service users must not be left without access to medication prescribed for them by their GP. DS0000013307.V316943.R01.S.doc Timescale for action 30/07/06 30/07/06 3. OP9 13(2) 28/08/06 4. OP9 13(2) 31/07/06 5. OP9 12(1)(a) 17/07/06 Chaldon Rise Version 5.2 Page 25 Systems must be put in place by the provider to ensure that medication is ordered and received at appropriate times to ensure it is always available to the service users. 6. OP9 12(1)(a) For the registered person to obtain a supply of medication for the named service user who was ‘out of stock’ of one medicine For the registered person to ensure individual protocols are produced for administration of medication prescribed ‘as required’. The registered person must ensure that the contact details of the Commission for Social Care Inspection is added to their complaints policy. The registered person must ensure that all senior managers in the home have safeguarding adults training provided by the local authority i.e. Surrey County Council. The registered person must ensure that the home has a copy of the Surrey Multi Agency Procedures February 2005. The registered person must ensure that there is a refurbishment programme in place to ensure that all rooms and communal areas are decorated when necessary to ensure that all areas are of a good standard. The registered person must ensure that any gaps on the staff application forms have a written explanation. The registered person must ensure that a suitably qualified and competent person is appointed to manage the care DS0000013307.V316943.R01.S.doc 04/07/06 7. OP9 13(2) 31/07/06 8. OP16 22 20/07/06 9. OP18 13 20/06/06 10. OP18 13 18/07/06 11. OP21 23 04/08/06 12. OP29 19 & schedule 2 8 04/08/07 13. OP31 04/08/07 Chaldon Rise Version 5.2 Page 26 14. OP33 17 home. An application for the registration of a manager must be submitted to the CSCI as soon as possible and by the date shown. The registered person must 04/08/07 ensure that all policies and procedures are updated to ensure the welfare of the service users and that staff are using the correct procedures. 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 Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Chaldon Rise DS0000013307.V316943.R01.S.doc Version 5.2 Page 28 - 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!