Inspection on 21/05/07 for Chalkmead Resource Centre

This inspection was carried out on 21st May 2007.

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

Chalkmead Resource Centre 29/11/06

Chalkmead Resource Centre 30/11/05

Chalkmead Resource Centre 07/06/05

Chalkmead Resource Centre 27/10/04

Chalkmead Resource Centre 21/06/04

Chalkmead Resource Centre 19/12/03

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Chalkmead Resource Centre Deans Road Merstham Surrey RH1 3HE Lead Inspector Helen Dickens Unannounced Inspection 21st May 2007 09:45 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 Chalkmead Resource Centre DS0000013591.V335541.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. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chalkmead Resource Centre Address Deans Road Merstham Surrey RH1 3HE 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 644831 keri.sherwood@anchor.org.uk Anchor Trust Mrs Susan Rosalie Linfield Care Home 50 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (50), of places Physical disability over 65 years of age (12) Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users may be admitted in the categories OP (Older people) of whom 20 may fall into the category DE(E) Up to 12 people with physical disability over the age of 65 years may be accommodated PD(E) 29th November 2006 Date of last inspection Brief Description of the Service: Chalkmead is situated in Merstham, Surrey in a quiet residential area and is home to 50 older people. It is conveniently located for the local shops and not far from Redhill town centre. The home has five living areas with eight to 12 single bedrooms in each one. Each area has a lounge and dining room with a kitchenette. Main meals are cooked in the central kitchen and served in the dining room using heated trolleys. Chalkmead is on two floors and the upper floor can be accessed by a lift. The home is set around a nicely established courtyard with seating for residents. The home runs a welfare shop and money raised is used to provide outings and entertainment for service users. There is private parking to the front of the building. The registered provider is the Anchor Trust. The current range of fees are £446.00-£600.00 per person per week. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 8.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Sue Linfield, represented the establishment. A partial tour of the premises took place. The inspector spoke to six residents on a one-to-one basis and up to a dozen more over lunch. Two staff members and a visiting relative were also spoken with. One returned ‘comment card’ from a relative and compliments letters to the home were also used in writing this report. Three residents’ care plans and a number of other documents and files, including two staff files, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? All the requirements from the last inspection have either been met, or partially met in the case of some ongoing projects. The Statement of Purpose and Service User Guide have been updated and were readily available within the home. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 6 There is a lot of work going on to improve the home further, and the registered manager and staff were working hard on the new care planning arrangements, staff training schedules, and on action plans following the last inspection and internal audits carried out by Anchor. One third of residents now have the new style care plans and these are now kept locked on each unit; this was a recommendation from the last inspection to protect residents’ confidentiality. Risk assessments have also improved with a new format which is better suited to individual’s needs. New furniture and carpets have been purchased and the environment has been much improved. The reception area is now newly fitted out and offers a warmer welcome, with seating for residents or visitors who wish to linger for a chat. The handyman has also done some redecoration since the last inspection. The arrangements for staff training have improved with the majority doing the BTEC in dementia care, and most now having done vulnerable adults training. All staff have now done moving and handling training. A wall chart with all the training booked for the year is now displayed in the office. The manager said staff are now following the BTEC induction workbook. A follow-up inspection by the environmental health department in January of this year noted improvements in relation to the kitchen area at the home. Recruitment arrangements have improved and a comprehensive list of all staff recruitment checks has been compiled; this is an accomplishment given the home employs nearly 70 members of staff. A falls assessment log is now being completed for all residents at risk of falling and the home is liaising with the falls risk co-ordinator. The community matron is now giving training sessions to staff on issues such as skin care and continence. The complaints procedure has now been updated and was very visible within the home including in the entrance, on each unit and in residents’ rooms. What they could do better: Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 7 Three requirements from the last inspection have only been partially met. These concern the updating of care plans as the older type do not contain sufficient detail regarding how support should be delivered to residents. In addition, the training arrangements are still not reflected in a central log and therefore it is difficult to ascertain which staff have done which courses, and whether staff are being deployed according to their training and experience. There were also some shortfalls in recruitment records. In addition, some further work is needed on recording the administration of medication, risk assessments, and on more activities for residents. The courtyard and front of the building need tidying, and there were some minor decorative issues which are mentioned in the report. 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. The summary of this inspection report can be made available in other formats on request. Chalkmead Resource Centre DS0000013591.V335541.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 Chalkmead Resource Centre DS0000013591.V335541.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is good pre-admission information available for residents, and their care needs are assessed prior to them moving into this home. EVIDENCE: The Statement of Purpose and Service User Guide have both been updated as required at the last inspection. These information documents are in a friendly format and consist of a standard Anchor folder, with specific information about Chalkmead, including services and facilities, staffing and the complaints procedure. Contact details for CSCI have been changed and now show the new address in Oxford. One of the residents interviewed said he had been given this information when he moved in and a copy was in the back of his file. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 10 Assessments for residents were not fully inspected at this visit as they were found to be satisfactory during the November 2006 inspection. Residents have a social services assessment from the care manager (where the referral comes from social services) and an in-house assessment carried out by the home. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning arrangements have improved but more work needs to be done to ensure that all residents have the new service user plan. Arrangements for healthcare and the administration of medication are good. Residents reported that they were treated well by staff. EVIDENCE: Three residents’ care plans were sampled and one file showing the new format was also seen. The older ‘individual lifestyle agreements’ are now being replaced gradually by the new style ‘service user plans.’ The manager said that so far about a third of residents have these new plans and it is an ongoing project to ensure all residents have the new format. The older plans sampled had regular reviews and risk assessments had been up-dated. There was good evidence of residents being involved in drawing up and reviewing these plans and one resident who was interviewed seemed quite familiar with their plan. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 12 They are now kept locked in a cabinet on each unit making them more accessible for staff whilst protecting residents’ privacy. The older type plans are not very detailed in places, and in particular do not give much information on how support is to be given. The manager said this would be addressed in the new plans and a requirement will be made in this regard. Residents interviewed all reported that their health needs were met, and that health professionals were called in when needed, for example the GPs and district nurses. One resident showed the inspector the way the district nurse had been looking after her leg ulcer, and another said the home had called out the doctor twice because she had a cough. One visitor interviewed was also pleased about the timely intervention by staff when their relative needed medical assistance and then again when their medication needed to be reviewed. There are no pressure sores at this home and the manager said staff work closely with continence services to ensure that residents are correctly assessed in this regard. There were no malodours in any of the bedrooms or communal living rooms despite a significant number of residents needing assistance in this regard. It was noted that there are not many opportunities for physical activity for residents and this was discussed with the manager and the activities co-ordinator. Medication arrangements were discussed with the manager and with one member of staff who was administering medication on one of the units. The home has now purchased trolleys for the secure storage of medication and these were securely padlocked. The trolley inspected was clean and tidy and there were no excess stocks of medicines kept. The community pharmacist visits six-monthly and the last pharmacist’s report was checked. The manager said the recommendations in the report had now all been met. One resident interviewed outlined how he administered some of his own medication with the assistance of staff and this was documented in his care plan. One resident who used oxygen had clear directions on the safety aspects on their door, and guidelines and a risk assessment on their file. The medication records for two residents were examined for the previous month and both had a few unexplained gaps. The manager said that gaps are usually followed up by the senior care worked on duty, and she would investigate what had happened. The manager was also asked to chase up the community pharmacist whose visit was now overdue. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 13 Staff were observed to knock on residents’ doors before entering bedrooms, and there were a number of good examples throughout the day when staff were observed to be respectful towards residents. For example, one staff member stopped their conversation to include a resident who had joined the group, and another staff member was overheard to thank a resident who took another by the hand to show them into supper. One resident keeps in touch with family by telephone and staff facilitate this by assisting the resident back to their room ready to take their telephone calls in private. Residents’ clothes are laundered separately so there is little chance of their clothes getting lost or being given back to another resident. There were no negative issues raised by residents in relation to their privacy or how they were treated by staff; all those spoken to were complimentary about the support they received. Several residents had incontinence supplies/catheter bags in their rooms which would be visible to visitors; the manager said that more discreet storage arrangements would be found to protect the privacy of residents. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have some opportunities for activities and to exercise choice and control over their lives. Residents enjoy their meals at Chalkmead. EVIDENCE: The home employs an activities co-ordinator for four days per week and the manager said they were trying to recruit a second person to cover the Friday/Saturday/Sunday each week. There was an outline plan in place, for example board games, bingo and hand care. On the day of the inspection one of the residents came up to the inspector to show off her freshly manicured and painted nails. The activities co-ordinator said this was especially popular and the activities plan showed two sessions per week. The inspector was told that the plan is only an outline as they need to take into account what residents want to do on the day – and also the abilities of residents, some of whom have dementia. For example, the board games played with these residents are more straightforward and are usually the older type games which they recognise, such as snakes and ladders. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 15 Staff raise money for an amenities fund to pay for extra treats for residents, for example there is a strawberry tea coming up in June. They also have occasional entertainment; one volunteer plays a keyboard, and another can sing. The manager would like to have an art class and one volunteer has expressed an interest in starting this up. The manager stated that staff encourage residents to help out on their unit, for example clearing the table after meals, to maintain some independent living skills. The activities co-ordinator said that residents are better in small groups or on a one-to-one basis which may account for there appearing to be not very much going on at times – with only one part time worker to cover five units this means she is very stretched. Arrangements need to be reviewed. There does not appear to be much opportunity for residents to go out and they never go out in the evenings though staff believe this is by choice as they would want to go to bed. There have been problems accessing free minibus transport and options were discussed with the inspector. There are currently no movement to music activities which are usually very popular in a care home setting and the manager said she would give this some thought. Chalkmead is also home to Chalkie the cat who is popular with staff and residents alike. A number of residents commented favourably on their involvement with him. The home has open visiting times and, as the door is only accessible with a keypad code, staff know who is coming in and out. They use some local volunteers who chat with and entertain residents and a few residents visit local shops and the park. There has been a referral to the local wheelchair service so that more residents can have their own wheelchairs for when they go out. One resident attends a local day centre. Family and friendship links are encouraged and the relative interviewed spoke very highly of the staff and the home. Residents are offered some opportunities to exercise choice and control over their lives. All the bedrooms visited showed residents had got some of their own personal possessions around them. Few residents manage their own finances and a significant number deposit small amounts of money at the home to use for everyday expenses such as hairdressing. The manager said those who like to pay in cash are given the cash to hand over themselves and therefore maintain some of their independent living skills. One resident administers their own insulin and this is facilitated and supported by staff. A list of advocacy services is available in the home though the manager said only one resident currently has an advocate as the remainder have friends or relatives to support them. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 16 Meals at this home came in for plenty of praise from residents. On the day of the inspection there was a catering tutor observing the trainee chef who is undergoing an in-house Anchor training course. For residents this meant that an extra option (haddock in a cream and mushroom sauce) was added to the already popular choice of beef stew and dumplings that day. The inspector tried one teaspoon of each item available to residents and found the food to be very tasty, with tender meat, light dumplings and properly cooked fresh vegetables. All those spoken to (in two units) enjoyed their meal and said the food was usually very good. The food is generally homemade with a few special diets, for example for diabetics. There were homemade cakes and biscuits for tea. Staff said currently there were no residents requiring assistance with eating but it was observed that there were staff on hand should this be necessary. The environmental health department visit showed there had been improvements in the kitchen area since the previous inspection. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements for making and recording complaints are good, but further work on training and recruitment procedures are needed to fully protect residents. EVIDENCE: The complaints record was inspected and all complaints received in the last year had been satisfactorily dealt with. A complaint received regarding the kitchen had been checked by the environmental health officer and a follow-up inspection noted that improvements had been made. The home has a complaints procedure, a user-friendly version of which is available inside the front door for visitors and also in the home. There is an in-house policy for the protection of vulnerable adults and the majority of staff have had training on this issue. Staff are given a booklet on rights and responsibilities which covers safeguarding matters in some detail. Two recent issues arising at the home have been correctly reported to social services and the manager is co-operating with the local authority to resolve these matters. However, the training records currently make it difficult to ascertain exactly which staff have yet to do the vulnerable adults training and estimates varied during the day. The manager said the remaining staff will be doing the course in June. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 18 There was also an issue found when sampling recruitment records which could have placed residents at risk and this was discussed with the manager. These issues are the subject of requirements under the training and recruitment sections of this report. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Chalkmead offers a homely environment which has recently undergone considerable refurbishment. Arrangements are in place to keep the home clean, pleasant and hygienic. EVIDENCE: The home is generally well decorated and maintained and a number of improvements have been carried out since the last inspection, including a new reception desk and a coffee table with chairs so that residents have somewhere to sit and chat in this area if they wish. There is an inner courtyard with chairs, tables, pots and bird feeders which is safe and secure for residents. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 20 There are new carpets in the hallway and stairwells. Residents spoken to were happy with their rooms and four rooms were visited by the inspector; they were found to be clean and fresh smelling and residents had many personal items on display. The visitor interviewed said they were happy with the room chosen by their relative. The home had just had a delivery of new furniture and all lounges had new chairs and sofas. The bathrooms and toilets were also clean and tidy and some had some nice homely touches including blinds, plants and pictures. The home also has some water coolers for residents and staff to enjoy chilled water; the manager said these were very popular with residents in the recent hot spell of weather. The premises are accessible for those with impairments – the inner courtyard is secure to enable those with dementia to move around freely. The upstairs corridor is open to all residents, though the stairs have a keypad to keep residents safe. The premises are either on the flat or accessible by a lift so therefore no part of the home is out of bounds for those with a physical disability. The manager was asked to carry out a risk assessment regarding the upstairs landing where residents from one dementia unit can walk into the other unit on the same floor. Whilst it is good that residents have the extra space and freedom to move around, the manager must ensure that there are no unavoidable hazards in the other unit, such as liquid bubble baths and shampoos which are in some residents’ rooms, which haven’t been risk assessed. One bathroom had some cracks in the wall which needed attention. The inner courtyard and front garden area need some work as pots had not yet been filled with plants (some just had weeds) and the front area in particular needed a good sweep. There was also a skip at the front though the manager said this would be gone by the end of the week as the old furniture had now all been put out following the last delivery of new chairs. The home employs domestic staff for the general cleaning in the home and a laundry worker on five mornings per week; the care staff help out on other occasions. On the afternoon of the inspection several care staff were spoken to in the laundry. All seemed knowledgeable of the correct washing temperatures for laundry, and on the system for dealing with incontinence laundry separately. Each resident’s laundry is washed individually and they each have their own laundry bins and baskets to keep their clothes separate and ensure that their own clothes are returned to them. This is a very busy laundry room but was well organised and tidy. The laundry door is not locked when in use and the manager was asked to add this potential danger to the existing risk assessment on this room. There was also a slight odour in one toilet and the manager said she would have this attended to immediately. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met by the number of staff on duty, and the home is committed to having a well-trained workforce. Recruitment arrangements are generally good but some shortfalls relating to initial recruitment checks need further work to ensure the safety of residents. EVIDENCE: The home has a staff rota and this was sent to CSCI as part of the pre-inspection information (PIQ). On the day of the inspection there were sufficient numbers of staff on duty to assist residents though one or two looked rushed at times. The dementia units have two members of staff, and the others have one. The staff numbers are based on the assessed needs of residents and the manager identified their need levels and the staff ratio calculations on the PIQ. Those residents interviewed had only positive things to say about staff and the compliments letters received also showed how much staff were appreciated by relatives. Comments such as, “Staff are always pleasant and helpful” were typical. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 22 There is a commitment to staff training at the home and the home’s own calculations show that over 70 of staff have at least NVQ Level 2 qualification or above. This is not easy to confirm as there is no central training record and individual staff files have to be looked at to calculate which staff have had which training courses. A requirement is made about this matter under Standard 30. Recruitment files are well kept and a very comprehensive list of criminal record bureau checks for nearly 70 staff was sent to CSCI in advance of the inspection. Some staff appeared not to have been checked against the protection of vulnerable adults register on the manager’s list, but she was quickly able to check in their files and confirm that these checks had been carried out. There is an equal opportunities policy in regard to recruitment and some staff are from different ethnic backgrounds to the majority of residents, though most staff appear to be from the same ethnic background as the residents they care for. One member of staff did not have their CRB number on the list, nor evidence at the home that one had been taken up. The staff member was telephoned and, whilst she no longer had a copy of her certificate, she had made a note of the number. The manager has looked into this following the inspection and contacted CSCI with the outcome. One of the three recruitment files sampled had shortfalls with regard to taking up references. This was discussed with the manager who was going to deal with this immediately. All staff involved in the recruitment process must be properly trained in correct recruitment procedures, and must have regard to the Care Homes Regulations 2001 (as amended) and in particular Schedule 2. A copy of this was given to the manager. There is a good level of training activity at this home with an annual training planner on the wall identifying which staff have been booked on which courses for the coming year. Anchor employs a part time back care trainer who, following and initial three day course, teaches other staff about moving and handling. All staff at the home receive this training as part of their induction, including housekeeping staff who have a course tailored to their particular role. All staff have an annual refresher. The manager said all staff exceed the three days paid training per year as set down in the National Minimum Standards. New staff use the BTEC induction workbooks and one of these was sampled and found to be satisfactorily completed. There were good individual records of training and certificates awarded but no central record which means it is difficult to see who had done what, and when their refresher courses are due. In order to have a proper staff development programme, and to ensure staff are being deployed according to their training and experience, a central record must be compiled. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and there are some systems in place for feedback from residents and other stakeholders. Residents’ interests are safeguarded by the home’s financial procedures, and systems are in place to manage health and safety. EVIDENCE: The manager has been in post since 2005 and has the Registered Managers Award, and NVQ Level 4. She was the manager of another home prior to moving to Chalkmead. She has a number of management qualifications including a post graduate diploma and certificate in management. She is an NVQ assessor and is currently doing the NVQ verifier certificate. She keeps up Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 24 her own training and in the last year has attended training on protecting vulnerable adults, dementia care, back care and nutritional screening. There are clear lines of accountability within the home and externally with Anchor Homes. There are a number of methods by which the home receives feedback from residents and this includes on a day to day basis, to the manager or their keyworker, at quarterly meetings, unit meetings and during the Regulation 26 visits to the home by the provider. One resident interviewed was very clear about how he could raise concerns with his keyworker if there were any problems. Views of other stakeholders come from compliments and comments received (which are kept on file and were available for inspection) and from questionnaires sent out from time to time. A number of very positive comments had been received since the last inspection, mainly from relatives. These included: “Staff are understanding”, “A big thank you for all the care and kindness…” and, “We wanted you to know how much we appreciated your care.” The manager has started a relatives’ and residents’ evening four times a year and the next one is at the end of this month. The manager said the internal quality assurance processes were suspended some time ago as Anchor are changing their methods in order to fit in with the new CSCI AQAA quality assurance process. The home will need to demonstrate it has a plan for continuous self monitoring, including an annual development plan, and have regard to the other sub-clauses set out under Standard 33. The manager said very few residents manage their own finances and some choose to have small amounts of money deposited with the home to pay for everyday expenses such as hairdressing and newspapers. Records are kept electronically and by hand and the two residents’ accounts sampled were found to be correct. Anchor homes have an annual health and safety audit and recommendations are made – once these have been actioned, the home is then issued with a ‘safe site’ award’. The home’s award from last year is still current until July but their next inspection is booked for June. A number of policies were sampled including the home’s smoking policy, which takes into account the new legislation on smoking in public places being introduced in July 2007. The main laundry risk assessment was sampled and the manager was asked to add the risk of confused residents entering the laundry as the door is not locked. A risk assessment regarding the access of residents with dementia to the other unit upstairs must also be carried out. These are requirements under the ‘Environment’ section of this report. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 25 Water temperatures are monitored by the maintenance man and three outlets tested in residents’ bedrooms were all around the recommended 43C. There is an annual inspection of the water system and the 2006/07 inspection was on file. The environmental health officer visited in January and noted generally good standards and improvements since the previous inspection; the next planned visit is in 12 months. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 27 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. Standard OP7 Regulation 15 (1)(2)(ad) Requirement The ongoing project to renew care plans must be completed within a reasonable time-frame to ensure that all residents’ support needs, and how they wish to receive that support, are clearly set out. Partially met from 06/12/06 Arrangements for monitoring the correct administration of medication must be reviewed to ensure that any unexplained gaps in recording are quickly identified and remedied. Arrangements for provision of activities must be reviewed to ensure all residents can participate in suitable and fulfilling activities, and that sufficient staff time is made available to support them. Timescale for action 21/08/07 2. OP9 13(2) 21/06/07 3. OP12 16(2)(m) 21/07/07 Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 28 4. OP19 23(1) (a)(b) A risk assessment must be carried out on the arrangements on the first floor, whereby residents with dementia can move freely into the unit next door. The laundry risk assessment must be reviewed to include the fact that the door is currently not locked when the laundry is unattended. Recruitment practices must be reviewed to ensure records detailed in Schedule 2 of the Care Homes Regulations 2001 (as amended) are available for all staff employed by the home. Training must be given to staff who are involved in the recruitment process. Partially met from 29/12/07 28/05/07 5. OP29 19 Schedule 2 21/06/07 6. OP30 18.(1)(i)1 7.(2)9 21/07/07 The registered person must ensure that all persons employed in the home receive training appropriate to the work they are to perform including protection of vulnerable adults training. A staff development programme, and a central record of past and current training must be drawn up to ensure that any gaps can be addressed. Partially met from 29/02/07 Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 29 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 OP10 Good Practice Recommendations It is recommended that all catheter bags and continence supplies are stored more discreetly in residents’ rooms or elsewhere, to protect the privacy and dignity of residents. Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Chalkmead Resource Centre DS0000013591.V335541.R01.S.doc Version 5.2 Page 31 - 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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