Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 07/06/05 for Chalkmead Resource Centre

Also see our care home review for Chalkmead Resource Centre for more information

This inspection was carried out on 7th June 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a group of staff that are motivated and enthusiastic, some of them have worked at the home a long time. Relatives spoken to felt the staff have built good relationships with them and work hard to improve the quality of life. The home is committed to staff training and there is an ongoing National Vocational Qualification training programme. One member of staff was a Back Care assessor, which means staff are trained to support service users safely.

What has improved since the last inspection?

The home met the requirements made from the previous inspection. The home recruited a handyman who maintained the garden. Relatives and service users were happy with the garden and courtyard. One service user that had problems with her sight had her bedroom decorated in light colours to help her to see things better. The Chef/Manager regularly consults with service users about the menu and the food. Staff stated meals had improved recently.

What the care home could do better:

The registered provider must ensure management stability by recruiting an experienced manager with the appropriate qualification and skills to lead and manage the staff team. The Individual Lifestyle Agreement plans must be regularly reviewed to ensure they are up to date and that they reflect the needs of the service user. Other documents in the home such as the Statement of Purpose, the Service User Guide and the Complaint Policy must be updated to ensure information is accurate. The home must ensure that unnecessary risks to service users are eliminated by replacing the carpet in some areas on the ground floor and that bedroom doors are not wedged open. The management must ensure staffing on Bluebird unit is appropriate to prevent any lone working by staff and that adequate support is provided by an increase in the frequency of supervision of staff. The management must alsoprovide suitable and sufficient kitchen equipment to ensure adequate facilities for the preparation of food.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Chalkmead Resource Centre Deans Road Merstham Surrey RH1 3HE Lead Inspector Mr Deavanand Ramdas Announced 7 June 2005 th 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 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 and 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. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chalkmead Resource Centre Address Deans Road Mertsham Surrey RH1 3HE 01737 644831 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Anchor Trust Care Home 50 Category(ies) of DE(E) - Dementia over 65 (3) registration, with number of places OP - Old Age (50) PD(E) - Physical Disability over 65 (50) Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be admitted in the categories OP(older people) of whom 3 may fall into the category DE(E). 2. Up to 12 people with physical disability over the age of 65 years may be accommodated PD(E) Date of last inspection 27th October 2004 Brief Description of the Service: Chalkmead is situated in Merstham, Surrey in a quiet residential area and is home to fifty 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 twelve single bedrooms in each one. Each area has a lounge and dining room with a kitchenette where service users can entertain guests, make their own tea and coffee and light snacks. 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 shrubs, flowers and seating where you can sit and relax. 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. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a period of 5.5 hours. A full tour of the premises took place, staff, service users and relatives were spoken to and care records and other documents inspected. The inspector would like to thank the service users, staff and relatives for their comments during the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered provider must ensure management stability by recruiting an experienced manager with the appropriate qualification and skills to lead and manage the staff team. The Individual Lifestyle Agreement plans must be regularly reviewed to ensure they are up to date and that they reflect the needs of the service user. Other documents in the home such as the Statement of Purpose, the Service User Guide and the Complaint Policy must be updated to ensure information is accurate. The home must ensure that unnecessary risks to service users are eliminated by replacing the carpet in some areas on the ground floor and that bedroom doors are not wedged open. The management must ensure staffing on Bluebird unit is appropriate to prevent any lone working by staff and that adequate support is provided by an increase in the frequency of supervision of staff. The management must also Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 6 provide suitable and sufficient kitchen equipment to ensure adequate facilities for the preparation of food. 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. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3. Service users and prospective service users were provided with sufficient information to make an informed choice about admission to the home. Some information needed to be updated. Written contracts were issued safeguarding the tenancy of service users. The admission and assessment procedures are satisfactory ensuring the home is able to meet service users needs. EVIDENCE: The home had a Statement of Purpose and a Service User Guide that was displayed in the foyer. The Statement of Purpose was reviewed and dated October 2004. The Service User Guide was reviewed and dated January 2005. They contained useful information about how the home operated that included aims and objectives, philosophy of care and services and facilities on offer. Service users had a licence agreement that were kept in their Individual Lifestyle Agreement Folder (ILA). The agreements viewed were dated and signed by the service user. The home had an Admissions Policy. The inspector noted a staff arranging a needs assessment for a service user who had been in Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 9 hospital. ILA Folders contained a review of assessed needs by social services. The manager was informed the Statement of Purpose and Service User Guide needed to be updated to reflect changes in management, staff changes in the home and contact names with the Commission. The complaints section must state that a complaint can be made to the commission at any stage should a complainant wish to do so. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. 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. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10. The system for planning care is satisfactory overall but documentation is not up to date. This practice could potentially place service users at risk. Personal support in the home is offered in such a way as to promote and protect service users’ privacy and dignity. EVIDENCE: Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 11 The home had Individual Lifestyle Agreements (ILA). These were sampled by the inspector and had personal details, hobbies and interests, personal care, dietary guidelines, mobility plans, risk assessments, medication assessments and night support plans. The plan states the service user choices and preferences and is signed and dated by the service user. Key workers are allocated and assist service users with their chosen lifestyle. The home has a GP, chiropody care is provided by East Surrey Hospital and a dentist visits the home under the National Health. There was evidence of joint assessment and review of assessed needs by social services. Documentation in the ILA was found to be inconsistent, risk assessments were not dated and signed. Reviews of ILA were not undertaken regularly. The inspector noted one agreement was last reviewed on 12.10.04. One service user had a review of assessed needs on the 15.1.04. The complaints procedure and the service user guide in the ILA needed to be updated. The manager stated she would review the ILA with a view to improve it. During the inspection staff were observed to treat service users with dignity and respect. The inspector noted in the staff room a training session on dignity arranged for 15.6.05. Service users were addressed by their preferred names. The manager was observed to knock on bedroom doors and sought permission before entering their bedrooms. Some bedrooms had a telephone where service users could take telephone calls in private and for others a payphone was provided on the first floor. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals in this home are good offering both choice and variety and catering for special dietary needs. However, the home must provide sufficient and suitable kitchen equipment for the preparation of food. EVIDENCE: The home had a planned menu and an alternative menu. The inspector discussed the menu with the Chef/Manager who had an approved City and Guilds catering qualification. The menu was found to be healthy, well balanced and varied. On the day of the inspection service users were observed to have a lunch of chicken with sauce, mashed potatoes, and cabbage and a choice of dessert. Meals were nicely presented and mealtime was relaxed and unhurried. The inspector observed staff to offer assistance to service users where appropriate. Staff and service users interacted with each other during lunchtime. One service user stated she had selected her meals the night before from the alternative menu. She remarked the food is very good. Staff reported the quality of the food had improved since the return of the Chef/Manager. The inspector noted that the Chef/Manager consulted with service users about the menu and that she had kept written records of her meetings and surveys. The Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 13 last meeting was held in May 2005. The Chef/Manager stated that she needed new equipment in the kitchen to replace the food mixer, microwave, dishwasher, potato rumbler and the oven. She remarked that the management had promised to replace the equipment five weeks ago. The inspector had discussions with the manager who stated she would arrange for the equipment to be replaced in the next two weeks. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. The complaint policy required updating. Adult protection procedures and a whistle blowing policy were also in place to promote the welfare of service users. EVIDENCE: The home had a complaint procedure that was in the Policies and Procedures File that was kept in the office. It was dated August 2004.The local complaint procedure and complaint leaflets were displayed in the foyer. The Individual Lifestyle Agreement Folder had the local complaint procedure in it. The home kept a record of complaints in a complaint folder. The inspector noted the last complaint was recorded on 4.4.05. It was an event that affected a service users well being but had not been reported to the Commission. A relative stated she was aware of the complaint procedure and had used the procedure to make a complaint. Staff stated service users voted in the recent elections using the postal voting system. The home had a whistle blowing policy and Surrey Multi-Agency Procedures for the protection of Vulnerable Adults. The manager stated the company had a Learning Resource Centre and the advisor was responsible for staff training. The inspector sampled staff induction files that showed that staff had received appropriate training. The training folder had a record of staff names that had been booked to attend protection of vulnerable adults training. The manager was informed that the complaint procedure was in need of Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 15 updating as previously stated in the report and events that affect service users well being must be reported to the Commission without delay. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The standard of the environment within this home is good providing service users with an attractive and homely place to live. However, the carpets on the first floor must be replaced to eliminate unnecessary risks to service users. EVIDENCE: The home is well maintained with a good standard of décor throughout. On the day of the inspection the home was found to be clean, well ventilated and free of mal odour. The furnishings were of good quality and the lighting was appropriate. Carpets on the first floor were in a state of disrepair and posed a risk to service users who used walking aids. Carpets were secured using DIY tape. The toilet, bathing and washing facilities were clean and hygienic. The home was fitted with adaptations such as grab rails, hoists, assisted baths and toilets to help service users maintain their independence. The home had an emergency call system. Bedrooms were found to be clean, well presented and personalised with family photographs, ornaments, radio, television and other Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 17 items of personal interest. One relative stated that a bedroom was redecorated with light colours to help her mother see things better. The laundry had three washing machines and two dryers. The inspector noted information was displayed on laundering procedures, Control of Substances Hazardous to Health, risk assessments and safe handling procedures. The home operated infection control measures. Observations confirmed regular hand washing by staff and arrangements for the disposal of clinical waste. The home has a large garden and a courtyard that is well maintained. The garden has nice lawns, mature trees and flowerbeds. It is private and secure with wheelchair access. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. 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 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. The home had adequate staffing levels in place to meet service users needs. Overall however, arrangements for one unit required review. EVIDENCE: On the day of the inspection the number of staff on duty was found to be appropriate. On duty were the manager, an administrator, senior care officers, care assistants, domestics, chef manager, kitchen staff and a handyman. The staff rota was viewed and found to be accurate. However the daily numbers section was not filled in. The manager stated the staff rota would be changed to make it easier to read. The inspector had a meeting with staff who stated that the numbers of staff on duty had been reduced from eight to seven on the afternoon shift. This had resulted in lone working in Bluebird Unit on occasions. This was discussed with the manager who stated that two staff would be allocated to the Bluebird Unit with immediate effect. The manager stated staffing levels were reduced because the home had five voids. The home had a management information training pack and each staff had a training schedule. The home had training videos on abuse in care homes, infection control, Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 19 principles of care, managing challenging behaviour, food, diet and dementia. The manager stated thirteen staff had completed the NVQ Care Award, six were working towards NVQ Care Awards and five were working towards the assessor award. This information was recorded on a form that had NVQ and timescales for completion and kept in the office. The inspector sampled staff files and found evidence of regular training. Five staff stated they had the NVQ Care Award, one of whom was the Back Care Assessor. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36 Only limited progress has been made in the recruitment of a manager and as a result the staff team do not receive consistent leadership and management. This could affect the quality of care to service users and the matter needs to be resolved as a priority. EVIDENCE: The inspector had a meeting with staff who were unhappy with the previous management arrangements. A relative remarked the standard of care that her mother received was not good under the previous management arrangements. An experienced manager from another of the company’s homes had taken over two days ago. She stated she would remain at the home until a manager is Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 21 appointed. The chef stated the new manager was approachable and supportive. Other staff stated they hope things would now improve. The manager stated a staff team meeting had been booked to discuss the management and running of the home. The inspector observed staff to be enthusiastic, motivated and supporting service users positively. A relative remarked staff worked very well and they always had a smile on their face. Supervision was discussed. Staff stated they were supervised every three months. The inspector checked the Supervision Folder and found fourteen staff had been supervised in April 05, five staff in May 05 and none in June 05. This was discussed with the manager who stated she would delegate supervision responsibilities to senior care officers so that staff can be supervised more often. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 22 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 2 3 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 2 3 3 3 3 3 3 Score Standard No 7 8 9 10 11 Score 2 3 x 3 x Standard No 27 28 29 30 2 3 x 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 2 3 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 3 33 x 34 x 35 x 36 2 37 x 38 x Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 23 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 NMS1 Regulation 4(1)(c) Requirement The registered person must update the Statement of Purpose and Service User Guide to reflect changes in management, staff changes at the home and changes in contact name with the Commission. The registered person must ensure the complaint procedure is updated to reflect a complaint can be made to the Commission at any stage should the complainant wish to do so. The registered person must ensure (ILA) care plans and risk assessments are reviewed monthly and maintained up to date. The registered person must ensure that the carpet in the hallway and corridor on the ground floor is replaced. The registered person must ensure staff are supervised regularly every 8 weeks. The registered person must ensure that all events affecting a service user well being is reported to the Commission without delay. Version 1.30 Timescale for action 01.08.05 2. NMS16 22(1) 01.08.05 3. NMS4,7 15(2)(b) 01.08.05 4. NMS24 16(2)(c) 01.09.05 5. 6. NMS35 NMS38 18(2)(a) 37(1)(e) 01.08.05 01.08.05 Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Page 24 7. NMS38 23(4)(a) (c) 16(2)(g) 8. NMS38 9. NMS27 18(1)(a) 10. NMS31 8 The registered person must ensure that bedroom doors are not wedged open so as to contain the outbreak of a fire. The registered person must ensure suitable equipment is provided in the kitchen by replacing the food mixer, dishwasher, microwave and the oven. The registered person must ensure two staff are on duty on each shift during the day on Bluebird Unit to ensure the safety of service users. The registered person must appoint a permanent person to manage the home and an application for the registration of a manager must be submitted to the Commission as soon as possible. 07.06.05 25.06.05 14.06.05 01.09.05 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 Good Practice Recommendations No recommendations were made. Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 Chalkmead Resource Centre H58_s13591_Chalkmead_v220827_070605_stage4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!