Inspection on 12/09/06 for Chapel View Nursing Home

This inspection was carried out on 12th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Chapel View Nursing Home 21/01/09

Chapel View Nursing Home 29/01/08

Chapel View Nursing Home 12/10/05

Chapel View Nursing Home 31/05/05

Chapel View Nursing Home 04/03/05

Chapel View Nursing Home 06/05/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Chapel View Nursing Home Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN Lead Inspector Jayne Barnett-Middleton Key Unannounced Inspection 10:00 12 September 2006 th 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 Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chapel View Nursing Home Address Spark Lane Mapplewell Barnsley South Yorkshire S75 6BN 01226 388181 01226 380270 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) Chapelfield View Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Lynda Jackson Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons accommodated shall be aged 60 years and above There are 19 beds registered for nursing (N) and 20 for personal care (PC). 12th October 2005 Date of last inspection Brief Description of the Service: Chapel View is owned by Four Seasons Healthcare Limited. The home provides nursing and personal care and accommodation to thirty-nine older people. The home occupies a central position in the village of Mapplewell in Barnsley, close to shops, pubs, the post office and other local amenities. The home is a two-storey building. There are thirty-five single bedrooms and two double bedrooms. There is a passenger lift. The home has a garden area that was well maintained and accessible. The fees for the care offered at the home at 12/09/06 vary from £320 per week for residential care to £341.40 for nursing care. The homes statement of purpose, service user guide and complaints procedure is available in appropriate formats. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced visit conducted by Jayne Barnett-Middleton. Prior to the inspection contacts made to The Commission For Social Care Inspection, the homes service history and a pre-inspection questionnaire were examined. Ten service user questionnaires were sent to residents prior to the visit, of which three were returned. A fieldwork visit took place from 10am until 18.30pm. Opportunity was taken to make a tour of the premises, inspect a sample of records including care plans, residents’ finances and staff recruitment files. Four staff and four residents were spoken to. The registered manager was on annual leave at the time of the visit. However, the regional manager was present during the afternoon of the visit. The inspector wishes to thank the regional manager, staff and residents for their assistance and time throughout the inspection process. What the service does well: What has improved since the last inspection? The service user guide had been updated to include the homes terms and conditions. The menus had been reviewed providing a more varied choice for the lunchtime meal. There was improvement in the presentation of liquidised diets. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 6 An activities co-ordinator has recently been appointed which will increase the level of leisure and social activities that are provided. Staff confirmed that they had received refresher Adult Protection training to promote the protection of the residents. Contingency plans were in place for residents to access communal facilities in the event of the lift being out of order. The homes recruitment procedures were improved. Staff recruitment files did need to include the employees’ full employment history to ensure that the residents are fully protected. What they could do better: The information in one care plan checked did require reviewing to ensure that it was an accurate reflection of the residents care needs. Nutritional screening was undertaken for residents on their admission but improvements were needed to ensure that, where there was an identified need, the weight of resident could be monitored. The Staff was not always following the homes policy for the safe storage and administration of medication and therefore the safety and welfare of residents may be placed at risk. The practice of assisting residents’ to eat on an individual basis appeared improved. However, some practices observed did require improvement. One bathroom area was unable to be used because of the inappropriate storage of equipment. Previous arrangements to identify minimum staffing levels had been reviewed. There were some comments raised by staff, which could affect the quality of care provided to the residents. A training and development programme was in place. Some staff are still in need of infection control and health and safety training, although it is acknowledged that the training is scheduled to take place. Arrangements for staff supervision are in place, however, not all staff was receiving regular supervision to enable them to focus on care practice and development needs. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 7 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. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective residents were provided with the information that they needed to make an informed choice about living at the home. Resident’s care needs were assessed prior to their admission and their individual needs were reflected in their plan of care. EVIDENCE: The service user guide had been updated to include the homes terms and conditions. Three residents or their relatives, via the service user questionnaire, confirmed that they were provided with enough information about the home before making a decision to move there. A full needs assessment was carried out for all residents prior to their admission. Staff from the home also visited prospective residents prior to their admission and an assessment of their needs was completed. This confirmed Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 10 that the service was appropriate for the resident, and provided staff with the information to formulate an individual plan of care. The regional manager confirmed that residents who had been in need of a stay in hospital would have their care needs re-assessed prior to them returning to the home, to ensure that the home were still able to able the residents care needs. Two residents said that they or their relatives had visited the home prior to their admission to look round the home and meet the staff before making a decision to live there. During the visit one prospective resident and their relative had been invited to visit the home and to stay for lunch. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Residents’ assessed needs were reflected in their plan of care. The information in one care plan checked did require reviewing to ensure that it was an accurate reflection of the residents care needs. Residents had access to health care services, which met their assessed needs. Nutritional screening was undertaken for residents on their admission but improvements were needed to ensure that, where there was an identified need, the weight of resident could be monitored. Staff was not always following the homes policy for the safe storage and administration of medication and therefore the safety and welfare of residents may be placed at risk. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 12 EVIDENCE: Three care plans were checked, which outlined the action that was required by staff to ensure that the health and personal care of the residents were met. The format was detailed and included the resident’s communication, hygiene and mobility needs. Two of the three care plans checked had been reviewed monthly. One care plan checked had not been reviewed since July 06. Risk assessments had been developed for all residents, which identified the individual risks that were presented to residents on a daily basis including falls, and moving and handling. The risk assessments checked in one file had been completed on the residents admission to the home in February 06 but there was no evidence that they had been reviewed since that time to ensure that they were still appropriate to promote the safety of the resident. Residents spoken to said that their healthcare needs were met confirming that they did receive visits from their chiropodist and general practitioner when needed. One visitor, who visited their relative frequently, said “ They (their relative) always looks comfortable” and described the care that the staff provided to promote their health and wellbeing. Residents surveyed said that they always or usually received the medical support that they needed. Nutritional screening was undertaken for residents on their admission. Two of the three care plans checked did identify that there was a need to monitor the weight of the resident due to their diet or medical condition. One weight monitoring record checked identified that the staff were unable to weigh the resident due to their frailty. One record checked evidenced that the residents weight had been monitored until July 06. The record acknowledged that after July the staff were unable to weigh the resident but no reason was recorded as to why they were unable to do so and there was no record as to how regular the resident should be weighed. During the visit one visitor voiced concerns in relation to the health care of their relative. They stated that recently there had been insufficient continence pads, which had compromised the dignity and comfort of their relative. The regional manager confirmed that there had been a problem with the home running low on continence pads. She confirmed that in order to resolve the issue all residents had been re-assessed and that there was now a sufficient supply to meet the individual needs of the residents. The visitor was concerned that recently the “tissue viability nurse” had recommended that their relative take a regular bath in prescribed lotion due to dry skin and their relative was “still being given a shower”. The regional manager discussed the issue with the staff on duty that initially said that the Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 13 hoist available was inappropriate to bath the resident safely. However, instruction and a demonstration to staff, by the regional manager, did demonstrate to staff that the equipment provided was appropriate to bath the resident safely and as required. The inspector observed that residents were clean and appropriately dressed. Staff were observed to be assisting residents in a manner that respected their privacy and dignity. Medication was checked on a sample basis. There were some gaps on medication administration records where medication had been administered and not signed for. The medication for two service users had been changed. The Medication change was handwritten, with no signature as to who had authorised the change. Liquid medication was left on top of the drugs trolley after tea. This was removed and given to the nurse in charge to safely secure. Controlled drugs were securely stored and two staff had signed to confirm that the medication had been appropriately administered. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The staff at the home was providing some activities for the residents. An activities co-ordinator has recently been appointed which will increase the level of leisure and social activities that are provided. Residents were encouraged to maintain contact with their family, friends and the local community as they wished, enabling residents to continue to be included in family life and valued. The menus had been reviewed providing a more varied choice for the lunchtime meal. There was improvement in the presentation of liquidised diets. Some practices observed during the lunchtime meal needed improvement. EVIDENCE: During the visit the majority of residents were spending time in the lounge areas watching television, listening to music or reading. Three residents were asked if there were enough activities provided. Comments included “ not really” and “ I would like to go out more”. Two residents said that they were Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 15 satisfied with how they spent their day as “ I like to listen to my personal stereo” and “ I enjoy reading and doing the crossword”. Three residents or their relatives, via the service user questionnaire, said that there was usually, sometimes, or no activities provided. Suggestions to improve the level of activities provided included more trips out of the home and more activities for residents with dementia and sight difficulties. The manager, via the pre inspection questionnaire, said that the post of activities organiser had been vacant since February 06 and that despite advertising there had been little success in recruitment. In the meantime the staff at the home had organised events to celebrate Easter and the World Cup, organised various raffles and that residents had been taken out as often as possible. On the day the regional manager confirmed that an existing member of staff had just recently taken on the role of activities organiser and that more activities were to be provided. One resident, via the service user survey, said, “we have some ideas for when they start”. Residents said that they were able to receive visitors at any reasonable time. One resident, who had recently been admitted to the home, said that their relative was able to visit them for most of the day and stay for lunch. One visitor who visited their relative almost every day said, “ I am always made to feel welcome”. A varied and balanced diet was available. Since the last visit the menus had been reviewed. One resident spoken to was pleased with this improvement commenting “ we now have more choice at lunchtime.” Part of the lunchtime meal was observed. The meals served were well presented and looked appetising. The practice of assisting residents’ to eat on an individual basis appeared improved. Residents who needed help with eating were assisted by staff on an individual basis. In general the Staff were observed to be feeding residents discreetly and sensitively. However, One member of staff was kneeling to feed a resident rather than sitting beside them. One resident did appear to require some assistance to eat as they were not eating and was not prompted or supported by staff to so. Residents surveyed said that they always or usually enjoyed the meals provided. Residents spoken to during the visit commented “ its o.k.” and “smashing”. After lunch residents who were able to comment said that they had enjoyed their meal. The inspector saw menus and a good range of food was recorded, however, the menu on display in the inspector’s opinion was inappropriate as it was on A4 paper, included the menus for the week and was in small writing and not easily seen on the notice board. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The complaints procedure was included in the service user guide and identified the procedure to be followed should anyone wish to make a complaint. The homes adult protection policy and procedure promoted the protection of residents from harm or abuse. Staff confirmed that they had received refresher training to update their knowledge and were conversant with the action that they should take should they suspect any abuse at the home. EVIDENCE: The home’s complaints procedure and complaints were recorded in a bound book. The manager maintained a log of any complaints made to the home and the action taken to resolve the complaint. Since the last visit no complaints have been made to the Commission For Social Care Inspection or to the home. One visitor spoken to said that the staff team were “approachable” and that “I can say anything” should they have any concerns in relation to the care of their relative. Concerns raised by one visitor, in relation to the care of their relative, during the visit were dealt with immediately by the regional manager. (Please refer to Health and Personal Care and management and administration) The adult protection policy and procedure had not been updated to include the contact details of the local adult protection officer. This was addressed during Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 17 the visit by the regional manager. Three members of staff spoken to confirmed that they had recently attended Protection Of Vulnerable Adults (POVA) training and were able to describe the types of abuse that can occur and the action to take should they suspect any abuse at the home. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The home was clean, comfortable and well maintained. Residents were provided with an environment that was accessible and homely. Contingency plans were in place for residents to access communal facilities in the event of the lift being out of order. One bathroom area was unable to be used because of the inappropriate storage of equipment. EVIDENCE: The building was clean and free from offensive odours and residents had access to all parts of the home. There is a large lounge with interlinking doors that provided residents with the choice of watching television, listening to Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 19 music or privacy to read and talk to visitors. There was ongoing refurbishment of the lounge areas and since the last visit new furniture had been provided. The home was well maintained and the grounds were tidy, safe, attractive and accessible. One resident said they had enjoyed walking around the home with their relative due to the warm weather. A routine programme of maintenance was in place. There had been problems in the lift being out of order. The staff said that during this time contingency plans had been put in place. A lounge area had been created upstairs, residents were supported to dine in their bedrooms and a lift maintenance contractor had attended the home twice per day to manually operate the lift for residents to access their bedrooms and lounge areas if they chose to. Equipment continued to be stored in a bathroom making it unavailable to residents. Laundry facilities were sited away from all food preparation and storage areas. A sluicing disinfector was in place. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. In general residents’, relatives, and staff felt that more staff were needed to meet the needs of residents’. Previous arrangements to identify minimum staffing levels had been reviewed. There were some comments raised by staff, which could affect the quality of care provided to the residents. A training and development programme was in place. Staff confirmed that refresher training was scheduled to update their knowledge and competence. 33 of staff held a National Vocational Qualification Level 2 or 3 in care. Further staff was in the process of completing the award to ensure that the service is meeting the required target of 50 . The homes recruitment procedures were improved. Staff recruitment files need to include the employees’ full employment history to ensure that the residents are fully protected. EVIDENCE: The Regional Manager said that staffing levels had been reviewed. She confirmed that the level of staff provided had been calculated based on all residents being either nursing or high dependency and that the staffing hours Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 21 provided were actually over the required minimum. There were twenty-five residents living at the home at the time of the visit. The minimum staff provided, including a qualified nurse, was five staff for the morning shift, four staff for the afternoon shift and three staff for the night shift. Two weeks rotas demonstrated, that with the exception of two shifts, the minimum number of staff had been provided. Three residents, via the survey, said that there was usually staff available if they needed them. Comments included ‘ they seem to be short staffed all the time’ and ‘on occasions the staff are quite busy’. During the visit one visitor commented ‘ the staff do appear to be rushed off their feet’. Three staff spoken to felt that due to the care needs of the residents they did have little time to socialise with the residents. They confirmed that the minimum numbers of staff were provided but stated that some nurses on duty did not always assist in the personal care of the residents. This was discussed with the regional manager who confirmed that the nurses in charge were incorporated within the care hours provided. The manager, via the pre-inspection questionaire, said that staff training including fire, food hygeine, moving and handling and first aid had taken place during the past twelve months. Training specific to the needs of the resident for example peg feeding had also been provided. The Staff confirmed that a good range of training was provided. They confirmed that they had received refresher Adult Protection training and that they were scheduled to attend Infection Control training. Three staff files were checked, two of which were for staff that had recently commenced employment at the home. The files seen contained a range of information including two references, declaration of health and identification but did not contain the employees’ full employment history. Staff employed had undertaken a Criminal Records Bureau and POVA Check to promote the protection of the residents. The regional manager confirmed that any agency staff did not commence working at the home working at the home until the agency confirmed that all the required recruitment checks had been carried out. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. Staff meetings were held regularly. Arrangements for staff supervision were in place, however, not all staff was receiving regular supervision to enable them to focus on care practice and development needs. Residents’ financial interests were safeguarded by the procedures at the home. Improvements were required with some of the records kept by the home to safeguard residents’ rights and best interests. The medication and practices did not sufficiently promote and safeguard the welfare of residents’. Concerns raised by a visitor in relation to the safety of their relative had been dealt with appropriately. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 23 EVIDENCE: During the visit residents and visitors spoke positively about the staff commenting, “ They work hard”, “ they’re smashing” and “helpful”. A previous requirement to the review the quality of care and service provided and findings supplied to The Commission For Social Care Inspection had not been met. The staff spoken to said that monthly meetings were held by the registered manager to enable them to discuss the service. Three staff spoken to said that they were not receiving regular supervision. Arrangements were in place for residents who were unable to manage their monies. Monies were securely stored and records checked evidenced that residents were able to access their monies for hair care and personal items as they wished. Receipts were in place for all transactions and regular auditing of the accounts took place, safeguarding resident finances. During the visit one visitor raised concerns about their relatives safety. They stated that their relatives bedrails had recently been removed and, that in their opinion, this had placed their relative at risk from falling out of bed. The relative said that after discussing her concerns with the manager they had been replaced and were so during the visit. This was discussed with the regional manager who confirmed that residents had recently been reassessed to determine if they were still in need of bedrails. Where there was no identified need the bedrails had been removed to further promote the safety of the residents. One residents care plan, whose bedrails had been removed, was randomly checked. The risk assessment had been updated and identified that after observing the resident for a period of two weeks the resident had been assessed as presenting no risk of falling and the bedrails removed. The care plan checked did acknowledge that the resident was in need of checking every half hour, to ensure that they were safe. The night report seen, whilst detailed, did not record the frequency of how often the resident had been checked. The regional manager confirmed that this would be recorded on a separate monitoring sheet. However, the frequency of the checks made should be included on the daily/night record to ensure that a consistent record of the care offered in maintained. Areas seen during the inspection appeared safe and accessible to resident No fire exits were blocked. Measures were in place to ensure the security of the premises and prevent intruders. Notifiable incidents were being reported as required by the regulations. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 2 2 Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 25 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. 2. 3. Standard OP7 OP7 OP8 Regulation 15 15 13,15 Requirement Resident care plans must be reviewed monthly. (Timescale of 31/12/05 not met) Risk assessments must be reviewed monthly. Where there is an identified need, the weight of the resident must be monitored and the frequency recorded in their plan of care. Appropriate equipment must be provided to ensure that where there is an identified need, the weight of frail residents can be monitored. Where practicable service users must receive the treatment as advised by healthcare professionals. Medication must be safely stored at all times. (Timescale of 12/10/05 not met) The MAR sheet for the medication identified must contain information on where instructions for the dosage of medication to be administered can be found. (Timescale of DS0000006474.V294726.R01.S.doc Timescale for action 30/11/06 30/11/06 30/11/06 4. OP8 12,16 30/11/06 5 OP8 12 01/10/06 6 OP9OP38 13 12/09/06 7 OP9 13 12/10/06 Chapel View Nursing Home Version 5.1 Page 26 12/10/05 not met) 8. 9 10 OP9 OP15 OP22 13 12 13,23 Medication administered must be 01/12/06 signed for. Staff offering assistance in 01/12/06 eating to residents must do so discreetly and sensitively. Equipment must be appropriately 01/12/06 and safely stored. (Previous timescale of 31/12/05 not met) Staffing levels must be to meet the needs of residents. (Previous timescale of 30 September 2005 not met.) Staff’s personal files must contain a record of their full employment history. Any gaps in employment must be accounted for and recorded. All staff must be trained in infection control and health and safety. (Previous timescales of 30 September 2003, 31 July 2004 and 30 June 2005 not met.) A review of the quality of care and the service provided must be undertaken in consultation with residents and their representatives and a copy of the findings of that report must be supplied to them and the CSCI. (Timescale of 31/12/05 not met) Records as required by the regulations must be up to date and accurate. 01/12/06 11 OP27 18 12 OP29 19 31/12/06 13 OP30 13 31/12/06 14 OP33 24 31/12/06 15 OP37 17 01/12/06 Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 27 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 Refer to Standard OP15 OP28 OP36 Good Practice Recommendations The menu for the day should be provided in an appropriate format. A minimum of 50 of care staff should attain NVQ Level 2 or 3 in care. All staff should receive appropriate supervision at a frequency of six times per year. Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Chapel View Nursing Home DS0000006474.V294726.R01.S.doc Version 5.1 Page 29 - 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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