Inspection on 20/07/05 for Chase Mental Nursing Home

This inspection was carried out on 20th July 2005.

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.

Other inspections for this house

Chase Mental Nursing Home 29/05/07

Chase Mental Nursing Home 08/05/06

Chase Mental Nursing Home 25/10/05

Chase Mental Nursing Home 23/11/04

Chase Mental Nursing Home 22/09/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Chase Mental Nursing Home 70 Vicarage Road Brownhills, Walsall West Midlands WS8 6AR Lead Inspector Richard Eaves Announced 20 July 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chase Mental Nursing Home Address 70 Vicarage Road, Brownhills, Walsall, West Midlands, WS8 6AR 01543 360611 01543 453200 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Heritage Healthcare (Midlands) Limited Mrs Janet Morgan Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd September 2004 Brief Description of the Service: The Chase is a care home providing nursing, personal care and accommodation for up to 22 adults with mental health difficulties. Owned by Heritage Healthcare (Midlands) Limited The Chase Care Home is situated in a residential part of Brownhills close to the town centre. Formerly the vicarage of St. James’ church it is constructed of brick with a tiled roof and has been extensively extended and modified. The accommodation consists of single and double bedrooms are situated on both the ground and first floors of the building. The laundry, storage and staff room are in the basement. It has three lounge areas and separate dining room. One small lounge is designated for smoking. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and undertaken by one inspector over one day. The focus of the inspection was on the delivery of care and included case tracking. The inspector had opportunity to speak with most service users and those willing to communicate were positive regarding all aspects of the home and care provided and they were happy to confirm that they were content with life at the home. The inspection also included a tour of the building, meeting with service users and inspection of records. Comment cards were received from 21 service users and 3 relatives/visitors to the home, 2 GP’s and 2 Care Managers. The responses from the GP’s, Care Managers and Relatives were all positive and no additional comments given. The service users responses were overall very positive with only activities suitability attracting some negative responses. There were 15 positive responses, 2 negative, 1 sometimes suitable and 3 no response. It is clear that the trips out are received very positively but the in-house activity is thought to be the area of limitation What the service does well: The home is very well presented to prospective clients both in general appearance and in the excellent sources of information provided to enable prospective service users to decide if the home will suit them. Arrangements for pre-admission visits and trial periods are seen by service users and staff as very helpful to settling in to the home. The home has very good assessment procedures and care planning systems in place and service users are confident that there personal needs are understood and can be met. The staff are seen to have excellent relationships with the residents interacting naturally, with empathy and deliver care as the person wishes, achieving a high level of satisfaction and sense of wellbeing amongst the residents. The home gives a high priority to obtaining service users views and demonstrate a commitment and flexibility in adapting services to address wishes where there is consensus. The property is well maintained and kept in good decorative order and in a clean odour free state. The home demonstrates a good commitment to staff training and provide for appropriate levels of formal supervision. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Standards Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitablity of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The homes statement of purpose/service user guide is a good source of information providing details of the service enabling service users and families to make informed decisions about admission to the home, this is confirmed at admission by contract. Confirmation that assessed needs can be met furthers enables service users to make an informed decision about entering the home as does the opportunity to visit and trial the services offered prior to admission. The staff group are stable, well established and collectively have the knowledge and skills to assess needs and to meet the assessed needs of the current service users. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 9 EVIDENCE: The Statement of Purpose and Service users Guide are provided as a combined document. This document has been subject to recent review is a useful, informative and recently reissued to each service user. The homes senior staff undertake pre-admission assessment of prospective service users using a research based assessment tool and confirmation that the home will be suitable to meet the assessed needs is provide prior to admission. Pre-admission visits, including overnight stays are considered essential in establishing that the prospective service user will settle into the home and be accepted by other service users. In addition to the Care Management Assessment/Care Plan the home undertakes its own needs assessment and covering items identified in standard 2.3 for adults and standard 3.3 for older persons. A range of risk assessments are also undertaken as required by the standards and on an individual needs basis such as smoking and going out alone. All assessments are subject to regular reviews. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 Care planning at the home is good, clear and consistent, providing staff with the necessary directions of actions required, to ensure that service users care needs are fully met and health is promoted. Service users are fully involved in all aspects of life at the home and are supported to make decisions for themselves and encouraged to be as independent as possible, even though this may mean taking risks. This is supported by a procedure for dealing with unexplained absences. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 11 EVIDENCE: A sample of case files were inspected and used for case tracking and found to contain care plans that were drawn up to address assessed issues and problems and these were kept under frequent review. The inspector found the language used in the documents to be user friendly with plenty of evidence of service user involvement in all aspects of assessment, care planning and reviews. Monitoring charts derived from the care plan were available as were records of GP and Consultant visits. The case files while being up to date also appear accurate and are kept secure and confidential The service users were seen to engage in the day to day running of the home in such activities as shopping, keeping their rooms clean and tidy, laying the table for lunch, cleaning up the outside smoking area and keeping the gardens tidy and clearly gain pleasure and satisfaction from these voluntary inputs. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experiencd in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14, 15, 16 & 17 Service users are enabled to get out and about in the local community and the nearby town and take responsibility for their participation in the life of the wider community. The involvement of family and friends is encouraged in agreement with the service users wishes. The home provides a varied social and recreational activity programme that provides interest and pleasure for Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 13 service users. The meals are wholesome and meet the nutritional needs of service users while providing for choice and personal taste. EVIDENCE: The home provides a wide range of appropriate activities within and outside of the home on a daily basis. In-house art is very popular as is bingo and board games and these have seen to be occurring consistently. Local excursions on a daily basis include the cinema, swimming and church attendance for some and pub lunches for others. Farther a field have been trips to the safari park, a chase water, Lichfield Cathedral, Rugeley reservoir, Cannock museum and a garden centre. Recently a number went to Weymouth on a day trip and previous trips this summer have been top Blackpool and Weston Super Mare. The service users choose the trips they would like at regular meetings. Most service users access the local town shopping independently. Families are actively encouraged to be involved and participate in care planning where appropriate and sign the care plans to confirm their involvement. Some actively participate in the life of the home and attend regular meetings. Service users are offered a key to their private accommodation. Staff enter service users rooms only with the individuals’ permission and usually in their presence. Restrictions of movement and individual choice are kept to minimum and where agreed recorded in the case files. Service users were observed to rise at their own choice and move about the home and away from it freely. They are encouraged to keep their own rooms tidy and some undertake their own cleaning. Rules are kept to a minimum and service users appear happy to accept restrictions on smoking venues and intake of alcohol There is a four-week rotational menu in operation, which includes choice at the three main meals; supper is included on the menu. Lunch was served during the inspection and the inspector was invited to join the service users, the meal was appetising, tasty and nutritious and enjoyed by all. Service users meetings include discussion of the menus and opportunity is made to include personal preferences. Fresh fruit and vegetables are available daily. Service users are involved and assist with the shopping at the local shops and supermarkets and tables are laid before each meal time. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Service users are assisted to maximise their independence and control over their lives and staff respect their privacy and dignity and give support to achieve this. Healthcare needs are well documented and are compiled with the input of the individual service user. The care plans give clear directions to ensure that service users’ healthcare needs are assessed, recognised and addressed. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. EVIDENCE: The home routines are flexible although service users are encouraged to accommodate meal times and medication regimes within their personal routines they are generally encouraged to make independent choices. Every shift is led by a psychiatric nurse to meet the day to day mental health nursing Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 15 needs and each service user has allocated a key worker to provide consistency of approach to meeting the individuals wishes in respect of maintaining their routines and choices. During the inspection it was noted that service users are achieving good standards of personal hygiene and appearance. Service users have their physical, emotional and mental health needs met and the care plans evidence general practitioner and other health care professional support. A local chemist provides medication and the pharmacist provides advice as required and provides a report of quarterly inspection. Currently no service users are assessed as able to self administer and control their own medications. The manager confirmed that service users are all subject to regular medical review of their medication regimen. Arrangements for the receipt, recording, storage, administration and disposal of medicines comply with the homes policy and this standard and action is being undertaken to implement the new clinical waste requirements to dispose of untaken medicines. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16, 18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are sageguarded. (OP NMS 35) The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 16, 18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes to an environment that is safe from abuse. EVIDENCE: The concerns/complaints policy and procedure has been kept under review and no complaints have been received during the preceding year. The home has policies in keeping with national guidance and staff receive training in adult protection procedures provided by Social Services. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 - 30 The standard of décor and maintenance within the home is good providing the service users with a safe, comfortable and homely environment. EVIDENCE: A tour of the building including an inspection of some bedrooms that the inspector was invited to see were found to be mostly nicely personalised and included some items of own furniture. The level of furnishing is by agreement and a copy of this is kept on the case file. It was observed that approved locks were fitted to the doors and a lockable facility was available in each room. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 18 A sample of records of safety checks were inspected and show that windows are restricted, radiators are of low surface temperature type, hot water is controlled at close to the standard 43°c, emergency call is available and doors are fitted with intumescent strips and cold smoke seals. Since the previous inspection a sluice disinfector machine has been fitted on the first floor. The home was generally found to be clean and hygienic in all areas with one exception of a bedroom with a background odour that requires attention. The laundry is equipped with a washing machine with a sluice cycle and a programme that can meet disinfection standards The home has 4 bath/showers and 6 w.c. disbursed around the home providing convenient facility whether using the communal or own room. The communal areas consist of three lounges including a small smoking designated room that has a extractor fan, a separate dining room is available also with some comfortable seating, this area was observed to be used by service users to play a tabletop game. Overall the communal areas provide a comfortable, domestic environment although one lounge chair was seen to be split and the outside windows require cleaning. It was observed that good use is made of the courtyard service users preferring to sit and smoke outside. Some service users enjoy keeping the garden areas neat and tidy and plants watered. Security of the premises has been improved with the fitting of electronically controlled gates at the entrance. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 34 and 35 (Adults 18-65) and Standards 27,29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 36 Staff are enthusiastic, well trained, supportive and committed to maximising the service users quality of life. The recruitment practice, staff training and supervision all contribute to ensuring service users benefit from the skills and knowledge of the staff. EVIDENCE: All staff have job descriptions and the induction and foundation training at TOPPS standard clarifies roles and responsibilities and all staff receive a copy of the General Social Care Council code of conduct and practice and nurses receive a copy of the Nursing and Midwifery Council code of conduct. The team consists of qualified mental health nurses and carers who all hold the National Vocational Qualification at level 2 in care. The rotas show that a nurse and two carers are on duty during the day with scope to increase this on Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 20 a planned basis to meet needs such as escort duties. The night shift is covered by a nurse and carer. A sample of staff files were inspected including that of the most recent appointee were viewed and show that all necessary recruitment checks to ensure resident protection have been undertaken. The files also contain records of the supervisions that are undertaken and planned to provide at least 6 meetings each year, in observing the content of the supervisions it was agreed that these could be more beneficial if more attention was given to aspects of practice with consideration given to handling potential situations. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 39 and 42 (Adults 18-65) and Standards 33,35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 - 39 & 42 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities. The managers approach is open and positive and develops positive relationships amongst service users and with staff. The home regularly reviews its performance which includes seeking the views of service users and their families. Environment management and staff training in respect of health and safety ensures service users safety and welfare are protected. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 22 EVIDENCE: The manager is a registered nurse with a management qualification and has recently updated this by undertaking the Registered Managers Award. The manager is well regarded and liked by the service users and staff alike and this is apparent from the comment cards and in speaking with service users and staff as well as observing the interactions over the day. The manager undertakes regular surveys of service users views and uses the findings to influence and improve the delivery of care. Since the previous inspection these findings have been written up in report form. A further survey has recently been completed and a report is being written, the raw data of which shows a good deal of satisfaction with life at the home. A full range of servicing, maintenance and regular monitoring of services and equipment is undertaken, staff receive training in health and safety and first aid. Records of all accidents are recorded, using data protection compliant documentation and reported as necessary, an audit of all accidents is undertaken on a quarterly basis, the last two quarters showing there to have been 11 accidents all being minor in effect with none reportable or requiring hospital attention. Induction and foundation training is provided to TOPSS requirements. Overall the premises were observed to be managed to meet safety requirements. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 Score ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x x x x 3 3 3 4 Standard No 24 25 26 27 28 29 30 STAFFING 3 3 3 3 2 3 2 Score 11 12 13 14 15 16 17 Standard No 31 32 33 34 35 36 3 3 3 3 3 2 3 3 3 x x 3 x Version 1.40 Page 24 CONDUCT & MANAGEMENT PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chase Mental Nursing Home Score 3 3 3 x 37 38 39 40 41 42 43 E55 S20796 Chase Mental NH V231984 200705 Stg4.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 28 Regulation 16(2)(c) Timescale for action The registered person will ensure 30.9.2005 that worn or damaged furniture is replaced or repaired in a timely way. The registered person must 30.9.2005 ensure the external glass is kept clean. The registered person must 30.9.2005 ensure that the cause of malodour is identified and action taken to control it. The registered person must 30.9.2005 develop and expand the range of topics to be included in supervision sesions. Requirement 2. 3. 30 30 23(2)(d) 23(2)(d) 4. 36 18(2)(a) 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 22 Good Practice Recommendations The manager is recommended to keep the complaints records under review and document that the non receipt of complaints reflects the real situation. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 25 Commission for Social Care Inspection Halesowen Office, West Point Ground Floor, Mucklow Office Park Mucklow Hill, Halesowen West Midlands, B62 8DA 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. Chase Mental Nursing Home E55 S20796 Chase Mental NH V231984 200705 Stg4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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