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Inspection on 24/04/07 for Charlotte Rose House

Also see our care home review for Charlotte Rose House for more information

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

There is a comfortable and homely atmosphere, in which residents are supported to maintain their privacy, dignity and independence. The staff team provide this support in a respectful manner. Residents are able to make choices and decisions about their daily lives; and they are encouraged to share their views and opinions about the home. They are able to enjoy a good social life; and choose what activities they want to do, what they want to eat and how they want their care to be provided. They are supported to make use of local medical and general health services whenever they need to.

What has improved since the last inspection?

No requirements were made at the last visit to the home, but since the last key inspection in May 2006 there have been improvements made to the way in which the assessing, care planning and reviewing processes are carried out; and to the risk assessment process for residents. All of these records are now in place. There have also been improvements in the completion of medication records, which are now signed by staff immediately after a resident has taken their mediation. Staff rotas are now in place and include the registered manager; and there is a comprehensive induction pack available for new staff. There is an on-going programme of decoration and refurbishment, and since the last visit to the home in August 2006 many of the bedrooms have been decorated and have had new, good quality soft furnishings.

What the care home could do better:

Three requirements have been made at this visit, the first being that all care plans must contain clear details about how to provide the support for resident`s identified needs. This will ensure that all parts of the need including privacy, dignity and independence are met. It is acknowledged that some care plans do this. A second requirement is made to ensure that all staff have up to date training and knowledge about the processes in place to safeguard the residents from abuse. It is recognised that only one member of staff has not received up to date training, and that arrangements were made straight away to ensure that the staff member received training the day after the visit. The last requirement made is for recruitment records to contain all of the required information, including two written references, so that the recruitment process protects residents. Recommendations for good practice have been made about recording the contents of care plans reviews, and it is recognised that action was taken on the day of the visit in regard to this recommendation. It has also been recommended that an up to date satisfaction survey for visiting professionals be carried out so that they are able to share their views with the home, and that risk assessments for substances that are hazardous to health are reviewed and updated where necessary. Finally it is recommended that staff supervision records are kept individually and that the records are signed and dated. It is acknowledged that records are in place and demonstrate that staff are supervised regularly. However individual records will help supervisors to monitor the process more easily.

CARE HOMES FOR OLDER PEOPLE Chaucer House 1 Norwood Road Skegness Lincs PE25 3AD Lead Inspector Wendy Taylor Key Unannounced Inspection 24th April 2007 09:10 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 Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaucer House Address 1 Norwood Road Skegness Lincs PE25 3AD 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) 01754 762119 pcoulson@chaucerhouse102.wanadoo.co.uk Lonrush Ltd Mrs P D Coulson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (1) of places Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2006 Brief Description of the Service: Chaucer House is a home providing personal care to people who are over the age of sixty-five. It is situated in the residential outskirts of Skegness within a short car ride of the town centre. Local services within walking distance of the home include hotel-restaurant, post office and shops. The home comprises a detached three-storey building with the accommodation for residents on both ground and first-floor levels. A passenger shaft lift and stair lift has been installed and serves the upper floor. There are fifteen bedrooms, five of which are shared occupancy, although at present no one shares a bedroom. The home is registered to provide accommodation for twenty persons, nineteen categorised as old age and one as physically disabled under the age of sixty five. To the front of the premises there is a patio area for sitting out and a small lawned area to the rear. There are no on-site parking facilities for cars although on-street parking is available at the front and side of the home. Seven residents were living at the home on the day of the visit. Current fee rates range from £335.00 to £409.00 per week. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place during April 2007 and the visit to the home was carried out over approximately 6½ hours on one day. Since the last key inspection in May 2006 there have been two further visits to the home to look at the progress made with outstanding requirements. All of the requirements were achieved by the second visit in August 2006, and the areas of improvement are referred to below. At this visit the care received by three residents was followed in detail. Those residents and others spoke about their experience of living at the home; and their personal records, general house records and staff records were looked at. Staff were spoken to and the care being provided was observed. Information already held by the commission was also used as part of this inspection process. Residents made comments such as ‘I am very happy with everything’ and ‘this is the best home I’ve lived in’. Other comments made by residents and staff can be seen in the main body of the report. What the service does well: What has improved since the last inspection? No requirements were made at the last visit to the home, but since the last key inspection in May 2006 there have been improvements made to the way in which the assessing, care planning and reviewing processes are carried out; and to the risk assessment process for residents. All of these records are now in place. There have also been improvements in the completion of medication records, which are now signed by staff immediately after a resident has taken their mediation. Staff rotas are now in place and include the registered manager; and there is a comprehensive induction pack available for new staff. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 6 There is an on-going programme of decoration and refurbishment, and since the last visit to the home in August 2006 many of the bedrooms have been decorated and have had new, good quality soft furnishings. 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. The summary of this inspection report can be made available in other formats on request. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make their own decisions about where to live based on comprehensive information; and they are assured that the home can met their needs by way of a thorough assessment process. EVIDENCE: Pre inspection information shows that there are policies available for referrals and admission processes. There is an up to date statement of purpose and service user guide available within the home, and all of the residents spoken to said that they had chosen to live there. Surveys indicate they have all received contracts for the placement and they were given enough information about the home before moving in. Also in the surveys two residents said that they had a chance to look around the home before moving in. Admission and on going assessments are available in residents files. They are signed by the resident to indicate their inclusion in the process, and they cover Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 9 needs such as vision, foot care, mobility, nutrition, memory and risk. Staff also explained how people who use the home for short stay breaks are assessed at each admission, and provided evidence of the specific assessment process. There have been no new admissions since the last inspection visit, and the home does not provide intermediate care. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s privacy and dignity is maintained throughout the care process, and they are supported to maintain their independence. The provision of health and personal care is based on assessed needs and resident’s wishes, but they would benefit from more detail being available in care plans and reviews. EVIDENCE: Individual care plans are in place for residents, and they said that they knew about their care plans. The plans were signed by them to indicate their agreement and involvement. Records show that staff have received training in how to develop care plans; and during discussions with them staff demonstrated a very clear and detailed knowledge of residents current health and social needs, likes and dislikes. The care plans cross-reference with assessments and cover needs such as maintaining independence, personal safety, personal care and mobility. Although the plans set out the support Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 11 required they do not always contain details of how to provide the support for example, a plan may say that a resident needs help with bathing but it may not say whether they need help to put the soap onto a flannel, or if they prefer a specific time of day to bathe. Records show that the plans are reviewed on a monthly basis by highlighting the date of the review with the signature of the person completing it. However there are no details of the content of the review recorded in the plan. Action was taken straight away to develop a format for clearly recording the contents of reviews. There are records of visits to or from health care professionals such as GP’s and District Nurses. Residents said that they could see their GP whenever they need to and in private if they wish. One resident described weekly visits from the District Nurse, which was evidenced in records. Staff were observed to knock on doors before entering, use residents preferred names and titles, and discuss needs in private with residents. Residents said that staff are very respectful and help them to keep their dignity. One resident said that staff ‘help us to do things for ourselves whilst we still can’; another said that staff ‘see to my needs very well, and do things how I ask’. Another resident said that they (staff) introduce people by their surnames and ‘then you decide for yourself whether you want them to use your first name or not’. Pre inspection information shows that there are policies available regarding infection control, medication, continence, privacy and dignity, choice and independence. In surveys received prior to the visit residents indicated that they get the care and support they need, staff are available when needed, and they get the medical support that they need. One resident commented ‘if I ring they (staff) come quickly’. Medication records are completed in full and there are appropriate storage arrangements in place. Administration procedures were followed appropriately on the day of the visit, and staff confirmed with residents if they wanted ‘when necessary’ medication before dispensing it. There are lockable storage facilities in resident’s bedrooms for medication that they administer for themselves. There are also risk assessments and agreements to self-administration within individual files. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a varied social life, which meets their expectations; and they benefit from a wholesome and varied diet. EVIDENCE: Surveys received prior to the visit indicate that residents think that there are enough activities available to them. On the day of the visit residents and staff described activities and outings such as going to the circus, going to local theatres, seaside trips and sing-a long evenings. Residents also described going for walks independently if they wish, going shopping and playing games such as dominoes and draughts. Several residents said that they enjoy spending time in the garden, and one described raised herb beds that have been built so that they can continue to grow plants. Residents made comments such as ‘you always get a choice of what you want to do’ and ‘you are always asked if you want to join in, but you don’t have to’. Records contain information about what activities residents have taken part in, and staff were able to demonstrate how they encourage people to make Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 13 choices. Residents described how visitors are made to feel welcome and said that they are able to receive visitors whenever they want. On the day of the visit staff were observed spending time with individual residents, engaged in whatever activity they requested such as chats, draughts and doing word puzzles. Residents were also seen going out with relatives. During the lunchtime meal there was a relaxed atmosphere and the dinning room tables were laid very nicely. Residents sat wherever they chose to and they said that they could eat in other areas of the home, including their rooms, if they wish. The menu was displayed in the dinning room with the alternatives clearly listed. Food was presented nicely and home made soup and desserts formed part of the menu. Residents made comments such as ‘we get delicious food’, ‘chef always makes us things that we like, and asks what we want to see on the menu’, ‘chef makes me bread and cakes for my special diet’ and ‘the veg and meat is never hard or chewy, and I get the small portion I ask for’. Comments were also made in surveys such as ‘chef is very helpful’ and ‘if I fancy anything different I only have to ask’. Pre inspection information shows that policies are available in regard to food safety, nutrition and relationships. During the visit policies were also seen regarding cultural and religious observances. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by clear policies and procedures, and they are able to express their concerns in a responsive atmosphere. However they are at risk where staff do not have sufficient knowledge and training. EVIDENCE: No complaints or safeguarding adult referrals have been made since the last visit. Pre inspection information shows that there are policies available for safeguarding adults, accidents, concerns/complaints, confidentiality, risk assessing/management, and whistle blowing. Risk assessments are in place for issues such as the use of mobility scooters, self-medication, showering, use of personal space, slips and scalding. There is evidence in records that the assessments are reviewed on a monthly basis. Advocacy arrangements are recorded in individual files, and residents described how they are supported to maintain their voting rights either by help to go to polling stations or by postal systems. On the day of the visit residents said that they feel safe living at the home and one resident commented that ‘they (staff) always help you to sort out your Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 15 problems’. Surveys indicate that residents know how to make a complaint, and that they know who to speak to if they are unhappy. Surveys also indicate that residents think that staff listen to and respect what they have to say, and act upon the information. Records show that one member of staff has not received up to date training in safeguarding adult procedures. Arrangements were made for a training session to take place the day after the inspection. Staff did have a clear understanding of the complaints process and were able to demonstrate how they would manage such situations in line with policies and procedures. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a generally clean, safe and comfortable environment that meets their needs and expectations, however some areas of decoration detract from the homely nature of the building. EVIDENCE: A tour of the building on the day of the visit showed that the home was very clean and tidy, and it was generally well maintained and decorated. However the carpet in the entrance hall was not very well fitted and could have caused trips or falls; this was attended to straight away. The paint on some woodwork and doors in hallways is in need of repair, and there is evidence that this work is planned in the on-going maintenance programme. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 17 Bedrooms are individually decorated and furnished. They were all presented very nicely with good quality bedding and soft furnishings. One bedroom has recently had a toilet and hand basin fitted. Call bells are within easy reach of beds and sitting areas within bedrooms, and on the day of the visit were in working order. Appropriate signs are displayed where oxygen cylinders are kept. Residents said that they liked their rooms and described them as ‘light and airy’, and one resident said that they have their own shower room located opposite their bedroom and described how pleased they were with the facility. Bedrooms are spacious, with room to use any equipment that residents need. There is locked storage for substances that are hazardous to health, which was being used appropriately on the day of the visit. Records show that maintenance of electrical wiring, central heating and the passenger lift is up to date, and there are policies available for managing health and safety, and substances that are hazardous to health. Hand washing facilities are available, and staff were observed to make good use of infection control measures such as wearing aprons and gloves where necessary. The garden areas are well maintained and tidy and residents said that they like to sit out in good weather. One resident said that they help to dead head flowers and have a raised herb bed to grow plants in. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of well-trained staff available to meet the needs and wishes of residents, but residents are at risk where safe recruitment procedures are not consistently followed. EVIDENCE: Pre inspection information shows that there are policies in place for issues such as recruitment, employment, using volunteers, grievance and disciplinary action. The information also shows that more than half of the staff team have achieved nationally recognised care qualifications at various levels, and there is planned training for safeguarding adult updates, Mental Capacity Act awareness and bereavement. Records show that staff receive an induction course based on a nationally recognised framework, which includes orientation to the home, understanding principles of care, communication and the organisation and their own roles. The new employee and their supervisor sign these records. Staff said that the induction process helps them to feel confident about carrying out their role. There is evidence in records that staff have received training in subjects such as first aid, basic food hygiene, care planning, diabetes, continence, Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 19 Parkinson’s Disease, fire safety, risk assessing, medication and safeguarding adults (see Standards 16-18). As well as formal training courses, there are also records of individual training sessions such as how to support residents to bathe. A new training room for staff is being developed within the home and already contains a TV and video/DVD, and a selection of other training materials such as, training videos for supervision and medication and information packs about palliative care, national service frameworks, moving and handling and diabetes. Staff said that there is good access to training and training is relevant to the needs of the residents. They said that there is good communication within the team, and there are enough staff on duty to meet residents needs. Rotas show that there is a consistent staff team and there has been no use of agency staff since the last inspection visit. Residents said that they are very happy with the support they receive from the registered manager and staff. Recruitment records generally contain appropriate information such as an application form, criminal record bureau checks and two references, however one file contained only one reference. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an atmosphere of openness within the home and everyone living or working there has an opportunity to share their views and opinions. The health, safety and welfare of residents are generally well managed. EVIDENCE: Residents and staff said that the registered manger is very supportive and makes herself available to everybody. They said that she would sort out any problems, and they have good opportunities to voice their opinions and say what they think. A resident said ‘I’m happy here and intend to stay for a very long time’. There is evidence in records of both residents and staff meetings. Minutes from residents meetings show that subjects such as activities, menus Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 21 and exercise are discussed; and minutes of staff meetings show that subjects such as training, confidentiality and rotas are discussed. There are records to show that staff receive supervision and they confirmed this during discussions with them. The records are not kept separately and are not signed and dated. Environmental risk assessments are available for issues such as tripping hazards, infection control, use of electrical goods and chemicals. Some risk assessments such as those for disinfectant and washing up liquid have not been reviewed for some time. Residents have individual risk assessments carried out for their bedrooms, which are kept in their personal files. Fire safety records are up to date and there is a fire risk assessment in place. There is evidence that fridge/freezer temperature records, food temperature records, and kitchen cleaning rotas are maintained. Pre inspection information shows that there are policies in place for quality assurance, emergencies and crises, equal opportunities, fire safety, record keeping and resident’s finances. Residents either manage their own finances or have legal safeguards in place to support them. Residents said that they keep their own personal allowances, however there are secure arrangements in place if they wish the registered manager to hold money for them. There is evidence that resident’s and relative’s satisfaction surveys are carried out, and the most recent survey shows positive outcomes in most areas. A survey format for other visitors to the home such as District Nurses, GP’s and social workers is in place but has not been carried out for some time. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All care plans must contain clear details about how to provide support for identified needs, so that those needs are met in the way that the person wants and requires them to be met. All staff must receive up to date training in relation to safeguarding adults so that they are able to appropriately protect residents from abuse and/or harm. Recruitment records must contain evidence of all information required in Schedule 2 of the Care Homes Regulations 2001, including two written references. This is to make sure that the recruitment process protects residents. Timescale for action 26/06/07 2. OP18 18 26/06/07 3. OP29 19 26/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 24 No. 1. 2. 3. 4. Refer to Standard OP7 OP33 OP36 OP38 Good Practice Recommendations It is recommended that details of care plan reviews be recorded within resident’s personal files. It is recommended that an up to date satisfaction survey for visitors to the home such as GP’s, District Nurses and Social Workers, be carried out. It is recommended that staff supervision records are kept individually, and the records are signed and dated by the supervisor and supervisee. It is recommended that all risk assessments for substances that are hazardous to health are reviewed and up dated where necessary. Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chaucer House DS0000034355.V334652.R01.S.doc Version 5.2 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. 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