Inspection on 28/02/06 for Chalfont Lodge Nursing Home

This inspection was carried out on 28th February 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

Chalfont Lodge Nursing Home 18/07/07

Chalfont Lodge Nursing Home 21/06/06

Chalfont Lodge Nursing Home 02/08/05

Chalfont Lodge Nursing Home 21/03/05

Chalfont Lodge Nursing Home 25/11/04

Chalfont Lodge Nursing Home 06/01/04

Chalfont Lodge Nursing Home 25/09/02

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Chalfont Lodge Nursing Home Denham Lane Chalfont St Peter Bucks SL9 0QQ Lead Inspector Mike Murphy Unannounced Inspection 28th February 2006 09:30 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 DS0000019191.V286940.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. DS0000019191.V286940.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chalfont Lodge Nursing Home Address Denham Lane Chalfont St Peter Bucks SL9 0QQ 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) 01753 888002 www.barchester.com Barchester Healthcare Plc Mrs Gillian Marie Rocker Care Home 119 Category(ies) of Dementia (48), Old age, not falling within any registration, with number other category (43), Physical disability (28) of places DS0000019191.V286940.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. General Nursing Care Specialist Nursing Care (Physically disabled 30 years plus) Date of last inspection 2nd August 2005 Brief Description of the Service: Chalfont Lodge is a large purpose built nursing home set in pleasant landscaped grounds adjacent to Gerrards Cross golf course and approximately two miles from the centre of Chalfont St Peter. It is operated by Barchester Healthcare PLC which owns over 160 nursing and residential homes across the country. The home can accommodate 119 service users across three areas of care: younger physically disabled, elderly physically frail, and elderly mentally frail. The home provides for a wide range of needs and abilities. All areas of the home are accessible by wheelchair. All 93 single rooms and 13 double rooms have en-suite facilities. Room sizes exceed the minimum standards. A first level nurse is in charge of each area: (i) Turnberry Unit (for younger people with a physical disability), (ii) Sunningdale Unit (for physically frail older people), and, (iii) Gleneagles, Wentworth and St Andrews Units (for mentally frail older people). There are many communal areas in the home including a library and large conservatory which overlooks a small lake. The homes dining room provides a pleasant ambience and good quality food is served by waiting staff. The home aims to provide good standards of care and good hotel facilities. DS0000019191.V286940.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors over the course of a day in February 2006. The methodology included discussion with the registered manager, unit managers, staff and residents, examination of documents (including care plans and staff records), and a walk around the home. This inspection primarily focused on the work of the unit for older people and of the unit for residents with dementia. The inspection assessed the home’s performance in relation to a selection of key standards. The inspection was also an opportunity to discuss a range of matters with the new registered manager and to check progress on matters raised at the last announced inspection which the same inspectors had carried out in August 2005. The home had experienced a number of changes at management level for most of 2005 and this may have contributed to apparent weaknesses in some systems. The new registered manager had recently made appointments to key management posts within the home. It is expected that this will introduce stability to the home and allow managers to address the weaknesses and matters identified in the report of this inspection. A very positive indicator has been the prompt response of the registered manager to this inspection. She has already begun to address points discussed at the feedback session. The statement of purpose and service user’s guide have now been revised and updated and subject to some further adjustment on complaints will fully meet the standards. Examination of care plans in the two care units inspected finds that staff practice falls significantly short of the standards expected. Current practice may have implications for the quality of care provided to residents and this matter requires urgent and effective action by managers. That said, residents in the dementia unit looked well cared for and were benefiting from the care provided. The home performs well in relation to resident choice and control over their lives. Residents have choice in relation to most aspects of care. The home provides a high quality environment which is generally well maintained. Examination of the home’s arrangements for the control of infection did not raise any significant concerns. Document management in relation to the home’s infection control policy would merit attention however, and it is suggested that the registered manager consider the use of alcohol to supplement existing hand washing routines. Examination of staff recruitment files raise significant concerns about current practice. The registered manager is required to give this urgent attention to ensure that staff recruitment procedures protects residents from the DS0000019191.V286940.R01.S.doc Version 5.1 Page 6 appointment of staff considered unsuitable to work with vulnerable adults and that files show evidence of this. The home has some very good quality assurance systems and it is expected that these, together with effective action on matters identified on this inspection, will ensure that the home provides a good quality service to residents, their families and other stakeholders. The inspectors would like to thank the residents and their visitors, the registered managers and her staff for their time and hospitality during the course of this inspection. What the service does well: What has improved since the last inspection? The new manager has been registered with the Commission. The home has revised its statement of purpose, service user’s guide and policy on the protection of vulnerable adults. DS0000019191.V286940.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000019191.V286940.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 DS0000019191.V286940.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 The home statement of purpose and service users guide are informative and well written. However, both omit to state that a complainant may refer their complaint to the Commission at any stage of the process. By not doing so it may deny a resident the opportunity of an external view by the Commission of the home’s investigation of the complaint. EVIDENCE: The registered manager had updated the statement of purpose and service users guide. The revised statement of purpose (August 2005 revision) includes all of the information required under Schedule 1. The service users guide contains the information required under standard 1.2 (NMS Care Homes for Older People). It is noted that the document states ‘The Commission regularly carries out inspection visits to the Home. A copy of the latest report is included with this guide’. With regard to the reference on complaints both documents omit to inform the reader that a complainant may refer a complaint to CSCI at any stage should they wish to do so. Both outline the internal complaints procedure and finish with the sentence ‘If you remain dissatisfied, then you may also complain to DS0000019191.V286940.R01.S.doc Version 5.1 Page 10 our Support Office or to the Commission for Social Care Inspection’. This needs to be amended to fully conform to the standard. Both documents are comprehensive and well written. At present both are only available in English. DS0000019191.V286940.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 Although care plans are in place for all residents, weaknesses were noted in the care plans examined in both units visited. These weaknesses may lead to residents care needs not being met through a failure to identify and accurately record needs, to effectively communicate matters within the staff team or to visiting professionals, or to undermine effective monitoring of progress and evaluation of care. EVIDENCE: Care plans were selected at random. All had initial assessments and had care plans developed from the assessment. All had had pressure damage risk assessments and nutritional assessments although plans had not been developed for two residents who had been identified as at risk. One resident had pressure damage for which there was no plan although the staff spoken to were aware of the damage and the daily continuation notes referred to treatment that had been undertaken. The progression towards healing was not clearly documented. There was evidence in one resident’s plan that she had pressure damage on admission although the extent of this was not recorded. There were no measurements or photographs of the damage. The DS0000019191.V286940.R01.S.doc Version 5.1 Page 12 service user had also had a nutritional risk assessment, which showed that they were at risk. There was no evidence of a dieticians input to the care plan although the resident had been prescribed additional food supplements. Care plans of residents in the unit for people with dementia contained a comprehensive assessment of care needs. Other forms included a falls risk assessment (included on the moving and handling form), nutritional risk assessment, weight (recorded monthly), a risk assessment summary, and a dependency chart. Psychosocial aspects of care are recorded in coded form and this is not considered sufficient for a unit caring for people with dementia. The content of care records varied from person to person - in at least one case these included a clothing inventory. Since this list is only valid at the time it was written it is difficult to see what it contributes to the record of care. Notes of progress or events were made on a key worker sheet, a nursing record and a multidisciplinary record. Some entries in these records were extremely brief (in one case ‘due care given’) and focussed almost entirely on physical aspects of care. One record included the comment (that the resident was) ‘interacting well’ without stating the nature, quality, content or context of the interaction. Care plans were reviewed monthly but frequently stated ‘no change’. The structure of care plans in the unit for people with dementia is the same as that in the units for people with physical disability or who are physically frail. This may support a bias towards recording physical care given and overlook the importance of addressing psychosocial aspects of care for this care group. The unit manager reported that the home was about to address staff training and care planning for people with dementia. This will include further training on Barchester Healthcare’s ‘Memory Lane’ programme and may include a consideration of the limitations or appropriateness of the present care planning system for that setting. The manager was also considering the role which a course such as the BSc (Hons) ‘Professional Practice with Dementing Illness in a Variety of Settings’ run by Thames Valley University might offer in changing and improving practice. Residents looked well cared for. Staff were attentive to residents needs and the unit was well organised. Evidence of the material aspects of the Barchester ‘Memory Lane’ programme included photographs and objects of the past. The benefits of the programme for one resident were discussed. It was reported that the resident, who had formerly been very distressed and restless, had gained comfort and pleasure through one element of the programme (handling a doll and being in ‘the nursery’). Her distress had eased and signs of wellbeing had increased. More generally, there is a need to ensure that all care plans are current and describe the care that is to be offered and that they are evaluated robustly on a monthly basis. All residents who are identified as at risk of developing DS0000019191.V286940.R01.S.doc Version 5.1 Page 13 pressure damage must have a care plan to minimise that risk. All residents who have developed pressure damage must have a care plan, which is monitored carefully and the rate of healing be recorded either by measurement or, with the residents consent, by photograph. Those with pressure damage should also have a nutritional assessment and be referred to a dietician where appropriate. There was evidence that the plans had been reviewed on a monthly basis although most stated no change over many months. Not all care plan entries were signed and dated. DS0000019191.V286940.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): 14 The home supports residents to maintain choice and control over their lives over a range of matters. Residents may have visitors at any time and see their visitors in private if they wish. This supports residents to maintain contact with family and friends. Residents may bring personal possessions in to the home which has many benefits. It allows them to personalise their room to their liking and differentiate it from others, it reinforces personal identity and maintains associations with the past – all of which have a positive effect on emotional well-being. EVIDENCE: Four residents on the unit for older people were spoken to. All confirmed that they had a choice as to when they got up or went to bed. They confirmed that visitors were welcome at any time and one said that she was pleased that her family could eat with her as they came from a distance to visit her. The nurse in charge said that residents were encouraged to personalise their rooms and many had chosen to do so. Three relatives were spoken to and they said that they felt welcome in the home at any time. There was no evidence seen that residents are given information about local advocacy services. There is a data protection policy. DS0000019191.V286940.R01.S.doc Version 5.1 Page 15 Residents in the dementia units require a moderate to high level of support and supervision. Two of the three units are on the first floor and residents wishing to go into the garden need staff supervision. One resident was happy for her room to be viewed and it was clear that the resident, her family and staff had supported her in personalising her room by bringing in personal possessions. The range of activities in the three units comprising the dementia care area varies. A ‘keep fit’ group had taken place on the morning of the inspection. In Wentworth there is a group activity programme every weekday morning. All residents have access to the music therapy programme. Some residents join those from other units in the downstairs lounge for social activities such as sing alongs. Residents are encouraged but are not obliged to participate in such activities. During the course of the inspection it was observed that while some residents enjoyed group activity, others preferred to sit on their own or in small groups. Staff were attentive to both. Residents may have access to their care plan. Relatives may have access with the permission of the resident or where a relative has power of attorney. The home does not manage residents finances other than small amounts of cash which is held for safe keeping for a minority of residents. DS0000019191.V286940.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 and 18 The homes complaints procedure, as summarised in the statement of purpose and service user’s guide, outlines a process which ensures that complaints are properly investigated within the home. However, it does not inform residents of their right to refer their complaint to CSCI at any stage of the process, thus potentially denying a complainant access to a CSCI view of the home’s investigation of the complaint. The homes policy on the protection of vulnerable adults provides comprehensive guidance to managers and staff on the nature of abuse, on reducing the chances of it occurring, and on the procedure to follow if abuse is suspected or observed. However, it does not fully take account of multi-agency procedures in Buckinghamshire, and does not, therefore, fully protect residents. EVIDENCE: The registered manager had revised and updated the statement of purpose and service user’s guide, each of which includes reference to the home’s complaints procedure. This does not fully conform to standards 16.4 which requires the registered person to ensure that residents are informed that they may refer a complaint to CSCI at any stage of the process. The registered manager has submitted a revised Barchester Healthcare policy for the protection of vulnerable adults. This is a comprehensive document but may need to be supplemented by a procedure which covers its application in this particular home. This needs to be fully compliant with the ‘Inter-Agency DS0000019191.V286940.R01.S.doc Version 5.1 Page 17 Policy and Procedures for Buckinghamshire’ which was issued in January 2006. It is noted in paragraph 1.15 of the Barchester policy that in reporting a situation where abuse is witnessed, that external reporting (i.e. outside of Barchester management channels)includes ‘…..if appropriate CSCI, the police and POVA team’. In such circumstances there is no discretion: CSCI must be notified under Regulation 37. There are clear local procedures established by statutory agencies which registered providers must follow. Paragraph 1.17 on confidential reporting of suspected abuse to external agencies should be strengthened by including local contact numbers for CSCI and the confidential Buckinghamshire Social Services ‘Careline’ reporting system. Paragraph 1.9 on the staff recruitment does not include reference to ‘POVAfirst’ and the need to conform to Department of Health guidance when appointing under a ‘POVAfirst’ check in advance of an enhanced CRB certificate. In paragraph 1.21 the policy states that ‘Staff who are not suitable to work with vulnerable adults may be referred for inclusion on the Protection of Vulnerable Adults Register’. The position is that there is a duty on registered providers to refer care workers to the list where any action or inaction on the part of an individual harmed a vulnerable adult or placed a vulnerable adult at risk of harm. DS0000019191.V286940.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 and 26 The home offers a good quality and generally well-maintained environment which provides residents with a safe and comfortable place to live. Arrangements for the control of infection are generally good but attention to points of detail would strengthen the protection of residents from the risk of cross infection. EVIDENCE: The home is situated in very pleasant grounds adjacent to Gerrards Cross golf course and about two miles from Chalfont St Peter. The environment is of a high standard and is generally well maintained. The grounds are attractive and well maintained. 93 of the bedrooms are single and 13 bedrooms are shared. All bedrooms have en-suite facilities (wc and either a shower or bath) and telephone and television. In addition to en-suite facilities there are 5 assisted baths and 1 assisted shower. There is lift access to all floors. Each care unit has a living and dining area and there are larger living and dining areas on the ground floor, including a very pleasant conservatory. DS0000019191.V286940.R01.S.doc Version 5.1 Page 19 Evidence of the organisation’s ‘Memory Lane’ programme in the form of objects, clothing and photographs from the past was noted in Wentworth and Gleneagles units. Other photographs include those of resident’s families and of their key worker in the unit. The unit manager said that a sensory room was soon to be created in one of the units. Bedrooms were bright, clean and comfortably furnished. However, one bedroom on the first floor had a very uninspiring view of waste bins from the window. This was discussed with the registered manager at the end of the inspection. The paintwork on a number of doors on Gleneagles unit was scuffed. The sluice in Gleneagles was used to store bins and was cluttered. A hoist is available for residents who require such assistance in bathing. Given the frailty of some residents the manager should consider whether an assisted bath is required in this area. There is a control of infection policy although two slightly different policies were noted on the Gleneagles unit. It is good to see that infection control is included in the audit programme in March and September 2006. There were notices in a number of areas stressing the importance of thorough hand washing and staff were observed to wash their hands following contact with residents. There is a separate laundry with washing machines that have the facility to wash at high temperatures the staff spoken to were clear about the protocols for managing soiled laundry and with the procedures for dealing with spillages. The laundry floor is impermeable. The unit had a sluice which was clean and tidy on the day of the inspection. The staff do not currently use alcohol gel hand wash and this should be considered. Although the net pants that are used to secure continence aids are washed at high temperatures residents do not have their own individual supply. This must be addressed and residents must have their own, labelled net pants to secure continence aids. DS0000019191.V286940.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): 29 Weaknesses in the home recruitment procedures mean that staff records do not contain evidence of the pre-employment checks listed in annex C to DOH POVA guidance. This places residents at risk of harm by increasing the potential for the recruitment of staff who are unsuitable to work with vulnerable adults. EVIDENCE: Five recruitment files were selected at random from those who had been recruited to the organisation since the last inspection. None were complete and all had different pieces of information missing. Recruitment file 1 The staff member had commenced work one month before the CRB disclosure had been received. There was no POVA first email record on file and there was no evidence in the file that the staff member had been supervised in line with department of health guidance during that period. There were no references on file and neither was there a copy of the Worker registration number. Recruitment file 2 All documents present with the exception of the worker registration number. DS0000019191.V286940.R01.S.doc Version 5.1 Page 21 Recruitment file 3 All documents present although one of the two references was from a neighbour who did not wish to give a reference. There was no evidence that the NMC confirmation service had been used to confirm nursing registration although a copy of the PIN card was on file and was in date. Recruitment file 4 All documents with the exception of one reference. It appears that the start date was April 2004, a POVA first was applied for in November 2004 and the full CRB disclosure was received in January 2005. No evidence in the file of supervision in line with DOH guidance Recruitment record 5 Start date March 05, POVA first May 05. Full CRB disclosure May 05. No evidence of supervision in line with DOH guidance. Limited leave to stay in passport although no work permit on file or explanation as to why work permit not required. Overall evidence of a lack of a systematic approach and an urgent audit of all records is required to ensure that all staff have the required documents. DS0000019191.V286940.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): 33 and 35 The home has a number of systems for monitoring and assessing the quality of the service. While these aim to ensure that residents receive a high standard of service the failure of the home take full account of CSCI inspection findings means that they are not as effective as they might be. The home has facilities for securely storing small amounts of cash and valuables on behalf of residents. This ensures that residents cash and valuables are safe and are accessible when the administrator or registered manager is on duty. EVIDENCE: The registered manager reported that the home carries out an annual survey of stakeholders including residents and their families, and of professionals and agencies such as GPs, visiting nurses, Thames Valley University and the wheelchair service. DS0000019191.V286940.R01.S.doc Version 5.1 Page 23 The home had recently acquired ‘Hospitality Assured’ (a quality assurance organisation) accreditation. The registered manager commented that Chalfont Lodge was the first care home to achieve this. A quality audit of one aspect of activity is carried out on a monthly basis. The programme for 2006 includes ‘health & safety’, ‘nutrition & dining experience’, ‘infection control’, ‘medication administration’, ‘documentation’, ‘personal care & professional practice’, ‘memory lane/activities’ and ‘customer service/home environment’. The process involves sampling a number of records and comparing practice against a number of key criteria. In the case of the care documentation audit 95 compliance is required to be considered a ‘positive outcome’. The minimum number of records to be checked is 10. The home analyses accident data on a monthly basis. The results of such monitoring were not examined on this inspection. The views of residents are obtained through the registered manager and other managers being present around the home every day, the registered manager’s ‘open door’ policy, through ‘fast feedback’ forms, and by adopting a positive view of complaints. Residents meetings are now to be established on a regular basis, and evening meetings, which will enable relatives to attend, are to be held in the dementia units. The work of the music therapist is a good example of an opportunity for lifelong learning for residents in the home. Policies are currently being reviewed and updated. The service has not been fully responsive to CSCI requirements and recommendations in 2005. The home does not manage money on behalf of residents with the exception of small amounts of cash which are managed through sundry accounts. The home has a safe for cash and valuable documents. The home is in regular contact with the local finance office in Berkhamsted. A full time administrator is employed to manage this and other financial matters. A small number of resident’s personal plastic folders were examined and the balance checked against the records. The balance was correct in all cases although weaknesses in recording discussed with managers on earlier inspections had not been addressed. DS0000019191.V286940.R01.S.doc Version 5.1 Page 24 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X X DS0000019191.V286940.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 5 Requirement Timescale for action 30/04/06 2 OP18 3 OP29 4 OP16 5 OP26 The manager is required to ensure that the section on complaints in the statement of purpose and the service users guide fully conforms to the national minimum standard on complaints. 13 (6) The manager is required to review the homes policy and procedure on abuse and ensure that it takes account of the procedures of local statutory agencies. 19 (1) (c ) The registered manager is required to ensure that staff recruitment procedures include verification of references and that the content of staff records retained in the home conform to Schedule 2 (as amended after the introduction of POVA in July 2004) 22 (6)(b) The registered manager is required to ensure that the complaints procedure states the right of a complainant to complain to CSCI at any stage 16(f) The registered manager is required to ensure that residents DS0000019191.V286940.R01.S.doc 30/04/06 28/02/06 30/04/06 01/03/06 Version 5.1 Page 26 who require them have their own supply of net pants, labelled with their name. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the registered manager review current practice in recording care given in the EMI unit so that care records include a fuller account of the residents day and reflect a person centred ethos. It is recommended that the registered manager assess the need for an assisted bath in the dementia care unit on the first floor It is recommended that, together with staff, the registered manager review staffing, work activities and workflow in the EMI units and ensure that care staff have sufficient time to spend with residents individually as well as completing essential tasks. It is recommended that the registered manager address potential weaknesses in financial procedures and ensure that all financial transactions involving resident’s monies are recorded. It is recommended that the registered manager consider the use of alcohol gel to supplement hand washing in the control of infection 2. 3. OP22 OP27 4. OP18 5 OP26 DS0000019191.V286940.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000019191.V286940.R01.S.doc Version 5.1 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. 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