This inspection was carried out on 10th January 2006.
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.
CARE HOMES FOR OLDER PEOPLE
Chase House Rest Home Chase House Hindhead Road Hindhead Surrey GU26 6AY Lead Inspector
Marianne Barham Unannounced Inspection 10th January 2006 11:25 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 Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 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. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Chase House Rest Home Address Chase House Hindhead Road Hindhead Surrey GU26 6AY 01428 652763 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) Mrs Kathleen Harris Mrs Kathleen Harris Care Home 16 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (8), of places Physical disability over 65 years of age (2) Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5 September 2005 Brief Description of the Service: Chase House is a large detached property located in the village of Hindhead. The service provides accommodation and care for up to sixteen older people, six of whom may also have dementia. The accommodation is arranged over two floors, with the first floor being reached by stairs or chair lift. At present all bedrooms are used single occupancy, however two of the bedrooms are registered for use as a double room. All bedrooms have a hand wash basin and some rooms have en-suite facilities or adjacent bathroom/toilet. There is a spacious communal lounge and dining room and also further seating areas throughout the home. There are several bathrooms and toilets located on boths floors, all of which have adapted facilities for those with mobility problems. The home has extensive gardens to the rear of the property and these are well maintained and accessible to the service users. There is parking for a limited number of cars to the front of the building. The home does not have its own vehicle but accesses a mini-bus from Age Concern for trips out. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 11.25am by Marianne Barham, lead inspector for the service. The inspection was undertaken over a period of three hours and was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The registered manager Mrs Kathleen Harris was present, records relating to the care of service users and running of the home were examined and a total of nine service users six members of staff and two visiting relatives were spoken with during this inspection. What the service does well: What has improved since the last inspection?
Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 6 The home has continued to provide a good standard of care and services to the service users and their friends and family. No requirements or recommendations were made at 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. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 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 Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 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 the following standard(s): N/A These standards were not assessed at this inspection. Please see report dated 5th September 2005 for detail on these standards. EVIDENCE: Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 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 the following standard(s): 8, 9 and 10 Service users health needs are met by the home and they are treated with respect and their right to privacy is upheld. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: All service users are registered with a local GP of their choosing. Specialist healthcare professionals are accessed through the GP practice. The GP visits the home monthly for non-urgent appointments and review of medication and/or health treatments. A chiropodist visits the home every eight weeks and sees all service users. The home has a policy and procedure in place for dealing with medicines that is in line with guidance from the Royal Pharmaceutical Society and all staff members who administer medications have read this. The medication is delivered to the home mainly in blister packs from a local pharmacy with advice provided to the home as needed. A record is kept of returned medicines. The medication administration records were examined and found to be in generally good order, however it was noted that one handwritten entry had not
Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 10 been signed by, the person making the entry. A recommendation has been made to address this. The medication was seen to be stored securely. Members of staff undertake a distance-learning course on the safe administration of medicines and a list of those qualified to administer medication is kept in the medication file. The home has a policy and procedure in place for respecting service users right to privacy and dignity and this is signed by all members of staff to show they have read the policy. All members of staff receive training at induction on the importance of respecting and maintaining the service users dignity. Members of staff were seen to treat service users with respect during this inspection. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 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 the following standard(s): 15 The home provides service users with a balanced diet that takes account of their individual needs and preferences. EVIDENCE: The home employs two cooks and there is a four weekly menu in place. This was seen to have a good variety of nutritiously balanced meals. Food was seen to be stored appropriately and there was a supply of fresh produce in evidence. The home purchases meat fresh from the local butcher and those meat products seen appeared to be of good quality. A record of each service users likes and dislikes and any dietary requirements is kept in the kitchen and this is reviewed regularly to make sure it is accurate. Service users spoken with were all very satisfied with the food provided by the home and all said they had a choice in what they ate. The kitchen was seen to be clean and well equipped and records of storage and food temperatures are maintained. The dining area is comfortable with the tables nicely laid at mealtimes. Members of staff were seen to support service users to eat their meals in a caring and dignified manner. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 12 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 Service users’ complaints are listened to and acted upon by the home. EVIDENCE: The home has a policy and procedure for complaints and all members of staff sign to show they have read this. A copy of the complaints procedure is kept in the service users guide, given to all service users on admission to the home. A record is maintained of any complaints received along with actions taken in response. The manager speaks with the service users on most days and responds to any concerns raised immediately. Service users and visitors spoken with were aware of the complaints procedure and all said they felt they could approach the manager with any concerns. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 13 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): N/A These standards were not assessed at this inspection. Please see report dated 5th September 2005 for detail on these standards. EVIDENCE: Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 14 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 and 29 Service users’ needs are met by, the numbers and skill mix of the staff team and they are protected by the home’s recruitment policy and practices. EVIDENCE: The home employs a head of care that is a registered nurse to take charge of all issues relating to the care of the service users. There is always a designated key-holder in charge of each shift and they are either registered nurses or care staff holding the NVQ level three qualification. The rotas were examined and show that there is sufficient numbers of care staff to meet the needs of the service users. The home employs two cooks, a cleaner, a gardener and a maintenance worker contracted to carry out repairs. The home has a policy and procedure in place for staff recruitment that is in line with current employment legislation. Personnel records were seen for several members of staff and these were found to maintained in good order with all necessary information supplied and checks carried out. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 15 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 The home is run in the best interests of service users. EVIDENCE: The home has a policy in place for quality assurance. Service users meetings are held weekly and any issues or concerns raised are discussed and acted upon. The home sends out a questionnaire to service users annually to obtain feedback from them regarding the care and services provided by the home. Responses to this survey are then collated and an action plan drawn up to address any issues raised. Responses to the most recent survey were seen to be very positive and complimentary about the home. At present the home is not seeking feedback from service users’ relatives or involved professionals and a recommendation has been made that this is done. Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 16 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 9 Good Practice Recommendations It is strongly recommended as good practice that all handwritten entries on the medication administration charts are signed by the person making the entry and also countersigned by a witness to ensure accuracy. It is strongly recommended as good practice that the annual survey carried out to obtain feedback from service users is also sent to service users’ relatives, friends and other involved people – such as GP, district nurse, vicar etc. 2 33 Chase House Rest Home DS0000041177.V261398.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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