Inspection on 24/08/05 for Chantry House Residential And Nursing Home

This inspection was carried out on 24th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chantry House Residential And... 14/04/08

Chantry House Residential And... 12/06/07

Chantry House Residential And... 12/06/06

Chantry House Residential And... 25/01/06

Chantry House Residential And... 03/02/05

Chantry House Residential And... 19/07/04

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

CARE HOMES FOR OLDER PEOPLE Chantry House Residential & Nursing Home Chantry Road Saxmundham Suffolk IP17 1DJ Lead Inspector Anna Rogers Announced 24 August 2005 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. 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. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chantry House Address Chantry Road Saxmundham Suffolk IP17 1DJ 01728 603377 01728 605645 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 Mr J Ellis Care Home 24 Category(ies) of Dementia (DE)24, Dementia over 65 (DE(E))24, registration, with number Mental Disorder (MD)8, Mental Disorder over 65 of places (MD(E))8, Learning disability over 65 (LD(E))1 Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Dementia (DE)24, Dementia over 65 (DE(E))24, Mental Disorder (MD)8, Mental Disorder over 65 (MD(E))8, Learning disability over 65 (LD(E))1 Date of last inspection 3rd February 2005 Brief Description of the Service: Chantry House is a registered care home, which provides nursing and residential care for up to 24 older people with mental health needs. The home is owned by Anchor Trust, a non profit making organisation, who provide care, support and housing to older people throughout the country. Chantry House is situated in the market town of Saxmundham and is close to all local amenities. Saxmundham is served by a local bus and train service and is a short distance from the main A12. The town is surrounded by open countryside and is a short drive from the Suffolk Coast. Chantry House opened in 1993 and is a purpose built resource, which is set back from the road and is surrounded by landscaped gardens. There is a large car parking area to the front of the building. Placement to the home is via the Social Care Services and Health Authority on completion of a Community Care and STARS assessment. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on Wednesday 24th August 2005 at 10am and was completed at 4.00pm. Evidence for the inspection was gathered from a variety of sources. The preinspection questionnaire provided information regarding residents and staff. Records relating to residents care were inspected and a selection of policies and procedures seen. Three comment cards were received from residents and two from relatives/visitors. During the inspection day five residents were spoken to formally and others informally. Two groups of visitors were spoken with about the care provided to their relatives. Discussions were held with the chef, administrator, four care staff, the manager and deputy manager and a domestic. The relationship between staff and residents was observed and a tour of the home was also made. What the service does well: The care of residents is seen to be important. There have been few changes in the staff team and it was clear that they work well together. The staff team are prepared to go beyond the call of duty for example keyworkers will shop for residents during their time off and are prepared to stay beyond their duty time if they are doing something for a resident. Food is seen to be important and the quality of the meals provided is excellent. The Chef does respond to individual needs, choices and requests. It was clear that the Chef would prepare nutritious and tasty food that is easy to swallow for those residents who are unwell to encourage them to eat. Residents are encouraged to personalise their bedrooms and one resident invited the inspector to see their room. They were clearly delighted with their new curtains and bedding and said, “I am also going to have my room painted in my favourite colour”. Staff have ensured that bedrooms of residents who are not so able are comfortable and welcoming. Visitors spoken to on the day of the inspection are very satisfied with the care given to their relatives and said “We are so pleased --- is here” “staff cannot do enough for them”, “a cup of tea is offered as soon as you arrive”, “ communication between the home and the family is so good”. The home is well maintained and the domestic staff work very hard to ensure all bathrooms and toilets are cleaned every day and resident’s bedrooms are kept clean and tidy. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 6 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. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents can expect that they will be fully assessed to ensure their needs can be met prior to moving into the home however residents receiving respite care cannot be assured that they will receive a similar service. EVIDENCE: All permanent placements to the home are accessed via the Social Care Services in partnership with the Mental Health Intermediate Care for Older People (MHICOP) team. All prospective residents are subject to an assessment prior to admission. There was evidence that these are detailed. There was evidence that outcomes of the assessment are included in the service users Individual Life Assessment plan (ILA). There is one resident who was admitted for respite care in December 2004 and remains at the home. Discussion with staff indicates that this resident’s abilities have decreased. There is a need for the resident to be re-assessed and steps taken to ensure their needs are met. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Residents can expect that their health care needs will be taken seriously with specialist support accessed when required and that when dealing with personal care, residents can expect to be treated with dignity and respect. EVIDENCE: As noted in the previous section of this report a clear system is in place to ensure residents requiring residential care are assessed and a care plan know as a Independent Lifestyle Agreement (ILA) (care plan) developed. The format used covers a wide range of areas including personal care, diet, medication, activities, mobility, continence and psychological and emotional support and areas of difficulty. Each section also has an evaluation for each area that staff comment upon on a daily basis. Four plans were seen during this inspection and generally they were informative and shown that they are reviewed monthly. There was information on one of the four plans relating to pressure care. The information provided good information about how the area was being managed and the notes indicated the progress made which was subject to a recommendation following the last inspection. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 10 However the ILA also identified a second pressure area that had no information to support the care being given. It was evident from discussion with the Deputy maanger that this area had healed and was no longer part of the plan. It is recommended that plans indicate where intervention is dormant. Risk assessments are also developed and form part of the ILA. From the sample seen it is clear that risks are identified but there is a need to develop the format used to show clearly who is at risk and what action is required to minimise the risk. There was evidence from observation on the day of this inspection of how staff managed the risk in practice but this needs to be confirmed in the risk assessment. There was evidence that resident’s health care needs are given a high priority. Files inspected showed that a record is kept of contact with GPs and other professionals including podiatry, opticians and psychiatrists. There was evidence following a doctor’s visit that the information is fed back during handover meetings between shifts, and changes to medication or additional prescriptions are collected following a doctor’s visit. There was evidence from observation of staff respecting service users privacy and dignity when providing personal care. There was evidence of staff knocking on bedroom and toilet doors before entering. There were other examples of good practice relating to the dignity and respect of residents by staff. One resident who was shouting out was being fed by a member of staff who was talking to them in a quiet, unhurried and relaxed manner. Another member of staff who was attending to a resident who is bed bound and quite poorly was heard to be communicating with the resident as they entered the bedroom and asking if they were comfortable. Other residents were also observed to being supported by members of staff who took time to listen to them although some were finding difficulty in expressing themselves. The staff acknowledged residents who were walking around the home and asking them if they were OK. Some residents had chosen to get up later than others and although it was close to lunchtime staff responded to resident’s requests for breakfast and provided opportunities for choice for example “what cereal would you like”, “would you like toast and marmalade” and a drink. Staff were aware of service users preferred form of address although this was not always recorded on the residents information. There is also a need to include the arrangements for contacting relatives if the resident becomes ill and/or after death. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14,15 Residents can expect the home to encourage contact with their families and friends. Residents can expect to be supported by staff to make their own choices as much as possible. Residents can expect to be provided with a varied and balanced diet. EVIDENCE: Discussion with staff and confirmed in discussion with relatives indicates that residents are encouraged to maintain contact with their family. Visitors spoken with said they were able to visit at any time and if they arrived over a mealtime they could order the meal choices. One group of relatives were visiting their relative who was very poorly and they commended the care being given. They said that staff were always available to talk with them and would provide a cup of tea. Visitors also confirmed that staff kept them informed and if their relative’s condition worsened they were confident that they would be informed and able to visit at such times convenient to themselves. Residents are encouraged to maintain their own routines with some residents opting to stay in bed later than others, going out into the community and deciding where they spend their day. Financial arrangements are discussed on admission and in consultation with their families. Advocacy services are available and the manager highlighted an instance where advocacy has worked positively for a resident to make contact with a member of their family. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 12 A recommendation to involve an advocate in the completion of service users comment cards from The Commission of Social Care Inspection (CSCI) has not been followed up which might account for the low return response. On a tour of the kitchen, the chef was spoken with about food preparation and food storage. Food was seen to be stored correctly and in good quantities. Fridge, freezer and food temperatures are recorded and food in these areas stored and covered appropriately. The kitchen was clean and tidy with a clear regime for ensuring cleanliness is maintained. The home provides a varied menu. On the day of this inspection residents were being provided with a choice of either salmon and prawns with a white wine sauce, duchesse potatoes and garden peas or one of the alternatives for example salad, omelette or jacket potatoes with various fillings. The main dessert was an apple and clove crumble with custard but again alternatives were available including cheese and biscuits with a selection of cheeses. It was evident from discussion with the chef that they cater for special diets including liquidised meals, vegetarian options and low sugar meals. It was noted that individual preferences are taken into account for example one resident did not like cloves so an individual crumble was available. Another resident will only eat certain cheese biscuits. The chef will also prepare home made soups for residents who are unwell or need to be encouraged to eat. The liquidised meals were individually prepared and presented in an attractive and appealing way. This attention to detail is commended for the choice provided. The chef also makes jam, marmalade and various chutneys as well as cakes and bread. Each of the three units has its own dining area and meals are transported from the main kitchen in hot trolleys to each unit. As noted residents requiring assistance with their meals are served earlier than the main mealtime to ensure staff are available to provide one to one assistance. A member of the catering team visits the units each day to check that residents are happy with their meals. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 There are clear systems in place to enable residents to express their concerns and protect them from abuse although the home’s procedure needs to be amended to ensure it meets with the expectations of the Suffolk Protection of Vulnerable Adults (POVA) inter agency policy, procedures and guidelines for staff. EVIDENCE: The statement of purpose and service users guide contains information on how residents/relatives can make complaints and contains the Commission’s details. None of the residents spoken with were able to give a clear view about what they would do if they wanted to make a complaint although one resident did say they would talk to staff. However relatives spoken with were clear they would talk with the manager but they felt they had nothing to complain about. There have not been any complaints made to the home since the last inspection. The Commission for Social Care Inspection (CSCI) did receive a concern from the local police when following a sudden death at the home they felt that the staff on duty were not clear about the procedures to follow. This highlighted a training need, which was followed up by the home in June 2005. The home also had a protection of vulnerable adults policy, detailing the procedures to follow to safeguard residents from abuse but this does contradict the local procedures particularly in relation to reporting an allegation rather than investigating it within the home. The policy and procedure needs to be amended to reflect this. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 14 The Registered Manager is to attend a Protection of Vulnerable Adults training course in October but it was evident from discussion with staff that this is also a training deficit within the team. Staff must also be made aware of and have access to a copy of the Suffolk Protection of Vulnerable Adults Inter Agency Policy and Procedures which also provides clear guidelines for staff to follow in the event of suspecting or receiving an allegation of abuse. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 Residents can expect to live in a clean, safe and well-maintained environment. EVIDENCE: The home is purpose built and offers a safe environment appropriate to the care of older people with mental frailty. The accommodation situated on two floors, serviced by a staircase and shaft lift has been attractively decorated with light and welcoming colours. The accommodation is divided into three living units, two situated on the ground floor and one on the first floor. Each unit has eight single bedrooms, a living dining room which has an integral small kitchen where drinks and light snacks can be prepared for residents at any time of the day or night. In addition to the en-suite facilities each unit has a communal assisted bathroom and toilet. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 16 The main entrance to the home leads directly into a spacious, well –furnished reception hallway, where residents can socialise together or meet with visitors to the home. The main kitchen and laundry room are situated off the main hallway. It was evident from observation, discussion with residents and visitors that residents are encouraged to personalise their bedrooms. One resident was clearly very proud to show the inspector their bedroom which had new curtains and bedding in the residents favourite colour. They also said that the walls were also to be painted. The relatives of one resident said they had been able to bring items of furniture and memorabilia, which they felt helped to make the “room feel like home”. One resident has a considerable amount of money and some of this has been spent on purchasing a suitable bed for their comfort. All rooms seen were clean and had facilities for clothing. All toilets and bathrooms seen were clean and fresh. Appropriate hand washing facilities are available although it was noted in one bathroom that the pedal bin has broken and should be replaced. Discussion with a domestic confirmed their understanding of the infection control procedures in place. They also confirmed they were provided with adequate cleaning materials and facilities to ensure their cleaning trolley is locked away when not in use. It was evident from discussion that the domestics work very hard to maintain the high standard of cleanliness and they have a system for ensuring that bathrooms and toilets are cleaned every day. They also confirmed that they followed a programme to undertake cleaning of resident’s bedrooms. The process for completing resident’s laundry was not inspected on this occasion but from observation it was clear that residents clothing is well cared for. Residents looked clean and appropriate for the weather conditions. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Residents can expect to be cared for by the appropriate numbers of staff however the organisation needs to encourage and support staff to achieve a minimum ratio of 50 of staff completing their NVQ level II qualification. Residents can expect that the recruitment checks undertaken for staff are thorough. EVIDENCE: The records show that the early shift has two trained nurses and a minimum of five care staff. This is in addition to the manager and deputy manager, the late shift had one registered nurse and five care staff. At night the waking night staff consists of one registered nurse and three care staff. Discussion with visitors confirmed the availability of staff when they visit and said they had no concerns about staffing levels. The pre-inspection questionnaire indicates that at the time of the inspection, the home only had three members of staff with an NVQ level II qualification and above which equates to 8.7 . Discussion with the deputy manager indicated that a further four were in the process of completing their course. Four members of the senior team hold the NVQ Assessors qualification. The manager confirmed that deficits relating to the recruitment of staff highlighted at the last inspection have been addressed. Only one member of staff has been appointed since the last inspection and they have since left. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 18 The manager confirmed that no members of staff undertake duties until they have had a satisfactory Criminal Records Bureau (CRB) check. The manager also confirmed their understanding that the CRB check must relate to the post at Chantry House. A Protection of Vulnerable Adults (Pova) First check is also completed which enables the member of staff to start their induction training but they are not left unsupervised with residents. The deputy manager is responsible for the training budget. They explained that they have attended a trainer’s course in back care and fire safety and will cascade this training to the staff team. It was noted at the last inspection that video material used for training staff in moving and handling (back care) was out of date. The deputy manager confirmed that the video is no longer used. While it was clear that the deputy is undertaking the training together with one of the trained staff who is also a trainer, the training records yet again did not reflect this. Other training including first aid and fire safety, which some members of staff have updated, also showed deficits in the training records. A repeat requirement is made. There was evidence in the training profiles of certificates of attendance for training relating to Mental Disorders, which had, no date or year included and another course titled Interface Pressure Monitor had the date but no year. This was brought to the attention of the manager. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,37,38 The manager provides clear leadership throughout the home and is well supported by staff who demonstrates an awareness of their roles and responsibilities. Residents can expect their finances to be safeguarded but the systems used mean they cannot be assured that they will receive the interest from their money. EVIDENCE: The manager is a qualified nurse and is experienced in caring for older people and running a care home. They are currently working towards the Registered Manager’s Award. A deputy who had been in post for nearly a year supports the manager. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 20 The inspector observed that there was an open and friendly atmosphere and relations between the staff team and residents were very positive. There was a relaxed and friendly atmosphere in the home, which was commented upon by relatives. Reports of senior managers’ monthly visits to the home as required by regulation have been sporadic in the last few months but the manager confirmed that the new area maanger is to take over this role and reports would be sent to The Commission for Social Care Inspection (CSCI). A quality assurance audit of the service has not recently been conducted. The maanger said that it was their intention to send questionnaires to residents and relatives. Advice was given to consider extending this to other professionals. The outcome of these surveys should be available to interested parties as set down in Standard 33.4. The administrator explained the financial arrangements at the home. Residents’ personal money is kept in individual wallets. Three of these were checked at random and all provided details of how money was spent and supported by a receipt that cross-referenced and the balance correct. There is also a central account titled “Residents Personal Monies Account” (RPMA) which residents’ money is paid into and then drawn by the administrator who is a signatory for the account, as residents require it. The account clearly shows the individual balance for each resident using this account but there is currently no system for residents to receive interest on their money while it is in the bank. Record keeping at the home is variable. Care plans are generally good with evidence of review although as stated in a previous section of this report there is a need to amend care plans when elements for example pressure area care is dormant. Training records should reflect the training undertaken. Training in relation to back care (moving and handling), first aid and fire safety training needs to be audited to ensure all staff has received up to date training. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 4 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x 2 x 2 x 2 3 Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 22 Yes 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 3 Regulation 14 Requirement The resident admitted for respite care which has been extened must be re-assessed and action taken to ensure their identifed needs are met. Staff must be familiar with the expectations of the Suffolk Protection of Vulnerable Adults (POVA) inter agency policy, procedures and guidelines for staff. The home’s Protection of Vulnerable Adults procedure must be amended to ensure it meets with the expectations of the Suffolk Protection of Vulnerable Adults (POVA) inter agency policy and procedures. The training records must be up to date and reflect the training attended by staff. Certificates evidencing attendance at training must have the date and year. The central bank account titled Residents Personal Monies Account” (RPMA) must be reviewed to ensure that residents receive proportionate interest. Timescale for action By September 30th 2005 By October 31st 2005 2. 18 13 (6) 3. 18 13 (6) By September 30th 2005 4. 5. 6. 30 30 35 18(1)(c) 18 (1) (c) 20 By September 30th 2005 Immediate By September 30th 2005 Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 23 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. 2. 3. 4. Refer to Standard 7 7 10 11 Good Practice Recommendations Care plans should indicate where intervention is dormant. The risk assessment format should be developed to show who is at risk and what action is required to minimise the risk. Resident information should record residents preferred form of address. Resident information should record the residents wishes for contact with their family/friends if they become ill and arrangements are to be followed in the event of their death. Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 5th Floor, St Vincent House Cutler Street Ipswich IP1 1UQ 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 Chantry House Residential & Nursing Home I54-I04 S24354 Chantry House V230746 050824 Stage 4.doc Version 1.40 Page 25 - 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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