Inspection on 31/08/06 for Chalk Hill

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chalk Hill 31/10/07

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

CARE HOME ADULTS 18-65 Chalk Hill Chalk Hill Waterhouse Lane Kingswood Surrey KT20 6DT Lead Inspector Suzanne Magnier Key Unannounced Inspection 31st August 2006 13:30 Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 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 Chalk Hill DS0000066903.V308508.R02.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalk Hill Address Chalk Hill Waterhouse Lane Kingswood Surrey KT20 6DT 01626 899930 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) chalkhill@moduscare.com Modus Care Limited Ms Nicola Patricia Miller Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: Chalk Hill is a detached property located in Kingswood, Surrey. It is a five bedroom property which benefits from a large garden to the rear of the property with off road parking to the front. The home currently accommodates three service users with learning disabilities. The home comprises of large communal areas including a lounge and dining room. Each service user has their own private bedroom, two of which are en suite. The home is situated close to the village stores and benefits from a public transport network with easy access to London and the local countryside. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On arrival at the home one service user was in and advised the inspector that the member of staff and another service user would be returning to the home in one hour. The inspector telephoned the registered manager who arrived promptly to conduct the key inspection. The home is currently supporting three service users and for the purpose of the report the inspector was advised that the people who live in the home are referred to as service users. This was the first site visit conducted since the home was registered with the Commission for Social Care Inspection (CSCI) in April 2006 and was conducted over four and a half hours. Upon entry to the home the inspector was given a visitor information form, which included guidelines of safety to visitors in the home including fire procedures. During the site visit the inspector looked at the Statement of Purpose, complaints procedure, the Service User Guide, service users care plans, risk assessments and daily records. Records also included menus and some medication records and storage of medicines within the home, policies and procedures, the staffing rosta, staff training and recruitment records. The inspector was given a tour of the premises by a service user and met with the other service users and staff during the afternoon. Comments from service users included ‘its great living here’ ‘the staff are really good and they help me’, ‘I get on well with the other clients’, ‘I don’t like getting up at 9.30 on weekdays’. One comment card stated that the service user did not know who to tell if they were unhappy. The inspector wishes to thank the service users and staff at Chalk Hill for their cooperation during the inspection. What the service does well: The home has robust care plans, based on a person centred approach and supports service users to maintain active, stimulating and meaningful activities in the community. Encouragement is given to service users to maintain links with family and friends and make promote new friendships. Risk assessments are well managed. The home is clean and hygienic throughout. The environment and private rooms of the service users are well maintained and personalised. The landscaped garden is accessible to service users. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 6 Staff recruitment, induction and training files are well recorded and staff spoke favourably of the training offered by the company and service users and staff spoke favourably of the day to day management of the home. What has improved since the last inspection? 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. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have sufficient information to make an informed choice if they would like to live in the home. EVIDENCE: The home was registered in April 2006. The home currently provides care and accommodation to three service users 2 male and 1 female. Each service user visited the home prior to moving in and each were part of choosing their bedrooms and the décor of the room. One service user brought a variety of their personal possessions on each visit. The inspector sampled the transition plans for the service users moving into the home which were noted to be well developed to ensure a smooth transitional move into the home. Each service user has a service user’s guide. Two service users had signed their copy and one service user’s relatives had their copy. The inspector and the registered manager discussed the amended regulations regarding the fees and terms and conditions of the home and it was noted that each service user has a copy of the terms and conditions of residency in the home. The home is currently looking into an advocacy service for one service user who has agreed to have an advocate. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning and risk assessments were current, well documented and recorded to ensure the service users wellbeing and health needs were evidenced as being met. EVIDENCE: All service users have moved from other Modus homes and have transferred their individual care plans to Chalk Hill. The inspector noted that necessary changes had been made for example one service users care plan has been developed from a hospital setting to a residential setting. The care plans are stored in the homes office and the registered manager advised that service users can have access to their care plans if they request. The manager advised that for two service users were aware that their care managers and the inspector could access their files. On arrival at the home one service user was in and advised the inspector that the member of staff and another service user would be returning to the home in one hour. The inspector telephoned that manager who arrived promptly to conduct the inspection. The service user alone in the house was aware of not Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 10 letting strangers into the home and appeared settled and relaxed to be in the house on their own. The inspector sampled a current risk assessment, which supported the service user to be in the house safely on his own. The manager explained that service users access to keys to the front door are based on a risk assessment and the support needs of the service users. One service user has a front door key and is enabled to stay in the house without staff for up to three hours in a day. The inspector noted that there were a variety of documents within the care plans to illustrate the difficulties a service user may experience and how staff could support the service user to become calm and self contained. Positive Response in the form of escort is used to support people to become calm. The inspector was informed that physical restraint is not used. Whilst sampling the risk assessments and agreed working practice guidelines the inspector noted that the documents had been signed by each member of staff to agree to support the service user in a safe and predicable way. A variety of risk assessments were sampled and included safe use of alcohol, personal care, personal boundaries, challenges related to specific situations, self neglect, support with personal finances, supported access to kitchen equipment and electrical equipment. The home has documented several disclaimers within risk assessments, which include a service user not having an extra chair in their bedroom, alternative preferred ways a service user likes to store their money and radiators which are not covered. During the tour of the premises the inspector noted that the home had not installed window restrictors on the first windows and it is required that the registered person must ensure that where the home has identified that window restrictors are not necessary that service users and their representatives are included in the decision of the risk management and where possible the service users must sign the risk assessment to confirm understanding. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home promotes service users to be involved in their community, to develop and maintain friendships and be involved in the running of the home and improving daily living skills for example household chores and cooking. The menus and choice of food provided were of a high standard. EVIDENCE: The aim of the home is that two service users who want to move to independent living will be enabled and supported to achieve their goal by the homes staff and additional support offered. Each service user has a named key worker. The inspector noted that the care plans and risk assessments detailed that the home offers encouragement and opportunity to develop and maintain service users independence and involvement in the community and to encourage two service users go out for a specific time on their own. In order to ensure their safety the home has supplied the service users with mobile phones and a business card with details of the home in the case of an emergency. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 12 Two service users are attending a local Croydon college and the home has a room that has a computer and quiet area that service users can use to study. The service users told the inspector that they are excited, slightly nervous but looking forward to going to college soon and that staff are very encouraging and supportive. All service users have a free bus pass which includes staff escort. One service user is being encouraged to use the train in order that they are able to travel safely and confidently. The service users are supported to be out and about and during the inspection one service user went to the local beauty parlour. One service user had gone to Sutton to go clothes shopping with a member of staff and have lunch out. Records evidenced that service users are encouraged to budget. The inspector met the service user and staff member when they returned from Sutton and the service users told the inspector that they had bought a hat and had lunch and it was a ‘good day’. One service user was undertaking music lessons and another is taking cycle training with additional staff support in order to assist the service users to take their cycle proficiency training. Documented evidence illustrated that the homes staff were aware that service users may express the need to have intimate relationships and Modus have a link with another company to provide a support system known as the Sexuality Policy Group which is designed to support service user who may feel vulnerable when entering into a new relationship. Care plans sampled that service users would be supported to have relationships. The manager explained that all service users first reviews have been booked over the next 2 months and it was evident through documentation seen by the inspector that staff have a monthly individual programme meeting to discus any topics regarding a service users care that needs to be discussed. The care plan sampled by the inspector showed that service users are part of the running of the home. During the tour of the premises a service user explained the chores rota to the inspector, which included cleaning, hoovering, dusting, mopping, and helping with the household shopping. The rota showed that each service user signs their name to the chore they will do. The inspector sampled the menus which were well balanced and offered a variety and choice of meals including a vegetarian diet. All food stored in the refrigerators and freezer was compliant with food safety standards and fresh vegetables and fruit was seen as available to service users. The meals are served in the dining room and breakfasts can be taken in the kitchen. The manager explained that meal times are a social event and important that service users engage with each other. Staff take their meals Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 13 with the service users at the two main meals. The inspector observed service users actively assisting with the preparation and cooking of the evening meal during the inspection and there was a lot of laughter and banter in the kitchen. The inspector was told that two service users have a cooking rota and each person cooks twice a week with support and assistance of staff. The inspector sampled a letter written by the registered manager to East Surrey PCT regarding advice and support for a service users meals and nutritional values. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has consistent recording and documentation to evidence that service users attend health care appointments. The homes medication procedures are robust to ensure the safety and wellbeing of the service users and staff. One care plan evidenced that the home are active in seeking the views of service users regarding their final affairs. EVIDENCE: The manager explained that all service users are self-caring and prompted by staff to undertake their personal hygiene. The care plans sampled by the inspector evidenced a full health history of the service users. Clear records evidenced attendance at appointments for health care checks and included visits to a nurse specialist, dentist, opticians and beauty therapy. The home have recognised that for one service user they have a choice to attend a health care appointments and the staff have worked with the service user to try and encourage them to attend the appointments. Nonattendance at the appointments was clearly documented a reasons for not attending explained. Records indicated that all service users were registered with a General Practitioner. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 15 The inspector sampled daily records and shift planning documents which evidenced a clear and consistent way of supporting service users. A night log for the sleep over staff was also well documented. The inspector sampled the homes medication policy and procedure, which was current and well documented to ensure the safe administration, storage and disposal of medicines in the home. One service user has medication on a daily basis, which is administered by staff who have undertaken the medication competency training in house and through their induction training. The inspector sampled the homes medication administration charts, which were well documented and contained no errors. Medicine stocktaking is undertaken on a weekly basis and signed by two staff and checked monthly by the registered manager. A nurse in the community administers one service users medication on a monthly basis. One service user, who is opposed to taking medication, is currently being supported by staff to consider taking alternative homeopathic medication under direction of their GP. The inspector sampled a document within a service users care plan, which detailed that the manager had spoken with the service user about their wishes regarding their final affairs. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure to demonstrate that complaints will be acted upon and a Safeguarding Adults (Adult Protection) policy and procedure in order that service users are adequately protected by the same policy and procedure. EVIDENCE: There have been no complaints or Safeguarding adult referrals since the home opened in April 2006. The home has a complaints procedure, which clearly documents the process that a complainant should take if they need to make a complaint. The home has a weekly service user house meeting and a weekly individual service users meeting where the service user has an opportunity to raise any concerns or complaints regarding the home. The inspector sampled that the home has the Surrey Multi Agency Procedures dated 2005 and No Secrets documentation. Two staff have yet to attend Safeguarding adults training and the manager explained that a Modus Team Coordinator will be undertaking the train the trainer course for this training which will be cascaded to the staff team in the near future. The homes induction incorporates the safeguarding adults training and what constitutes abuse. The inspector sampled the homes whistle blowing policy. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was viewed as clean and bright throughout. Service users rooms reflected individuality. Two requirements have been made regarding repairs in an en suite bathroom and dining area. EVIDENCE: The home has a relaxed, welcoming and open atmosphere. A service user took the inspector on a tour of the premises. The home offers a spacious and comfortable environment for the service users and it was noted that a high standard of cleanliness is maintained throughout the home. The inspector noted that the dinning room carpet was ill fitting and could be a potential slip/trip hazard. The manager advised that the flooring is specialised and the landlord has advised that they do not want nails to be inserted into the floor to secure the carpet. A requirement has been made that the carpet is secured in order to ensure that unnecessary risks to the service users are eliminated. The service user showed the inspector their bedroom, which was well decorated and contained personal items including books, videos, a desk, Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 18 computer, and an assortment of other items. The bedroom has an en suite shower with toilet and the service users expressed concern that the shower leaks and in their view is dangerous. The inspector noted that the flooring of the bathroom was lino tiles, which were ill fitting. It is required that the flooring is replaced and the shower repaired. The service user told the inspector that they prefer to use the shower downstairs. The manager explained that the plumber had visited the home in the morning to assess the situation and the home is awaiting a financial quotation. All communal areas of the home were noted as being well decorated and a new carpet in the hallway and stairs had been recently fitted. There are large communal areas, which include the lounge and the dining room. There is an area in the home, which is a small kitchen that the manager explained will be used to support people with daily living skills. The home has an enclosed garden, which is well maintained by the gardener. The home currently does not support service users who require specialist equipment. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust system for the induction, training development and recruitment and vetting procedures of staff in order to ensure that service users needs are met appropriately and safely. EVIDENCE: During the course of the inspection the inspector observed that the service users were aware of the roles and responsibilities of the staff. Each service user spoke favourably about the manager and staff of the home. The home currently employs six staff members two of whom are currently undertaking their National Vocational Qualification (NVQ) Level 2. Whilst sampling the staff training records the inspector noted that there were gaps in the statutory training for example First Aid and Fire safety. The manager advised that the training had been authorised within the next three months and staff were currently in their six-month probation. The inspector sampled documentation to confirm this arrangement. The inspector sampled the homes training and development policy. The home has an induction procedure, which includes a one day course in the house, and a two day induction which includes specified training including Aspergers Syndrome, Autism Spectrum Disorders, Medication and Infection Control. The Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 20 induction also includes awareness of the homes policies and procedures. All staff have a shadowing programme for 2 weeks and this includes meeting with the service users, understanding the aims, objectives and routines of the workings of the home, reading and understanding the service users care plans and competency training. The recruitment process involves the Modus Head Office and the manager who assists short listing applicants with other senior managers. The home does have a one full time vacancy and is deploying staff from another residential learning disability service owned by Modus. The staff recruitment files sampled by the inspector evidenced that sound recruitment practices were in place and all necessary pre employment checks had been made to ensure the safety and security of the service user. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the home is robust, service users and their representative’s views and opinions are considered and service users safety and welfare is well managed. EVIDENCE: The inspector observed that the homes current certificate of registration and insurance were displayed within the home. Throughout the course of the inspection the manager demonstrated a sound knowledge of the home and the support needs of the service users. The registered manager has achieved a National Vocational Qualification (NVQ) Level 4 in management and the Registered Managers Award, a Diploma in Psychology of challenging behaviour and an Honours degree in psychology. The staff and service users spoke favourably of the manager and her competencies to manage the home. Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 22 The inspector sampled documents which evidenced that the home has a six monthly Audit, which includes a questionnaire being sent out to various people including the service users representatives, family, care managers. The service users also have a questionnaire, which they can chose to complete to comment on the staff values, level of training, community access, the homes environment and quality of food. The inspector sampled some questionnaires that had been completed at the previous Modus Home, which were viewed as good practice in ensuring that the service users have a voice and can let the company and staff know what their views are about the service. The manager explained that there were some difficulties in some people not returning the forms however the home strives to ensure that Quality Assurance is undertaken. The next Quality Assurance survey for Chalk Hill will be due in October 2006. The inspector sampled health and safety records, which included fire procedures and evacuation of the building, the accident/incident book, water temperature and fridge/freezer checks. All records were current and well documented. The general maintenance records of the home were also well documented to ensure the safety and security of the environment. Chalk Hill DS0000066903.V308508.R02.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA9 Regulation Requirement Timescale for action 14/09/06 2 YA24 2 YA27 13.(4)(a,b,c) The registered person must ensure that where the home has identified that window restrictors are not necessary that service users and their representatives are included in the decision of the risk management and where possible the service users must sign the risk assessment to confirm understanding. 23.(2)(b) The registered person must ensure that the dining room carpet is secured in order to ensure that unnecessary risks to the service users are eliminated. 23.(2)(j) The registered person must ensure that the flooring is replaced and the shower repaired in a service users en suite bathroom. 21/10/06 21/10/06 Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 25 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 Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 26 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 Chalk Hill DS0000066903.V308508.R02.S.doc Version 5.2 Page 27 - 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. 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