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Inspection on 29/05/07 for Chase Mental Nursing Home

Also see our care home review for Chase Mental Nursing Home for more information

This inspection was carried out on 29th May 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

The home provides a comfortable environment in which to live. People commented that `staff look after us well`, and, `home is always fresh and clean`. The cleanliness of the home is maintained to a high standard. The staff demonstrated a good in-depth knowledge of the resident group and the conditions and dilemmas associated with mental ill health. Throughout the service there is a highly evolved understanding of the equalities and diversity needs of the individuals who use the service. People make decisions about their daily lives and are supported and encouraged with their individual choices. People are fully involved with the care planning and review processes; any restrictions that may be necessary are discussed and agreed.

What has improved since the last inspection?

The care plans for each individual have been reviewed and include management strategies for dealing with specific conditions. The dining room has been redecorated and the flooring has been replacedStaff have received training in first aid and other core and specialist topic areas.

What the care home could do better:

The manager spoke of the plans for replacing the carpet in the corridor for a more suitable type of material, a planned approach to the redecoration and replacement of furniture and fittings would assist with budgeting and ensure that all areas of the home are maintained at an acceptable standard. For the safe storage of medication the temperature of the fridge should have the maximum/minimum readings recorded daily. A system should be implemented to collate the recruitment documents into the personnel files.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Chase Mental Nursing Home 70 Vicarage Road Brownhills Walsall West Midlands WS8 6AR Lead Inspector Joy Hoelzel Key Unannounced Inspection 29th May 2007 09:30 Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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 Mental Nursing Home DS0000020796.V335796.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 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 DS0000020796.V335796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chase Mental Nursing Home Address 70 Vicarage Road Brownhills Walsall West Midlands WS8 6AR 01543 360611 0121 308 8007 agunputh@aol.com 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) Heritage Healthcare (Midlands) Limited Mrs Janet Nessie Morgan Care Home 22 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (22) of places Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Short, medium and long stay patients who require psychiatric care Date of last inspection 8th May 2006 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, which 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. Weekly fees range from £432.25 - £550.66 Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. Commission for Social Care Inspection Reports for this service are available from the provider or can be obtained from www.csci.org.uk Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five and quarter hours on Tuesday 29th May 2007. It was conducted by one Commission for Social Care Inspection regulation inspector. Twenty one of the forty two National Minimum Standards for Care Homes for adults (18-65) were inspected in addition to twenty three standards for Older People. Seventeen people are currently living at the home; many have been resident for several years. The registered manager was on the premises supported by two care staff, ancillary personnel were additional. The owner of the home was at the home during the morning of the inspection. Three case files were selected for case tracking, relevant documents were inspected, discussions were held with people living at the home, visitors, members of staff and the manager. Observation was made of the various daily activities and a tour of the premises was conducted. A pre inspection questionnaire completed by the manager, two relatives and two general practitioners surveys have been completed. Seventeen service users surveys some of which had been completed by the staff at the home have been received their comments are included in this report. What the service does well: What has improved since the last inspection? The care plans for each individual have been reviewed and include management strategies for dealing with specific conditions. The dining room has been redecorated and the flooring has been replaced. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 6 Staff have received training in first aid and other core and specialist topic areas. 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. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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 Outcomes 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 DS0000020796.V335796.R01.S.doc Version 5.2 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 suitability 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA 2. OP 3,6 Quality in this outcome area is good. Admissions are not made to the home until a full needs assessment has been undertaken. It is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate, so people can be assured that their needs will be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were selected for inspection and included the file of the person most recently moving into the home. One file contained a pre admission assessment based on the activities of daily living with comments, assessments and observations fully completed in all areas. A copy of the care needs details from the previous social care placement Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 9 had also been obtained prior to their arrival. This information was then used to generate an initial plan of care at the point of admission to the home. A placement confirmation letter is available and sent to the client and/or person assisting with arranging the placement. This person spoke about the move and stated that he felt he was ‘settling in ok’, with the staff, food and accommodation ‘alright’. The pre admission assessments were not available in the other files, as the people had been living at the home for a considerable period of time. Many people living at the home are residing on a long-term basis and as such admissions are minimal. The home does not offer an intermediate care service. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA 6,7,9. OP 7,14, Quality in this outcome area is good. The service involves individuals in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives and individuals are encouraged to make their own decisions and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All people living at the home have a plan of care, which is developed, agreed and reviewed with the full involvement of the individual. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 11 The three case files were selected for inspection all contained a full plan of care based on the activities of daily living, with additional monitoring and assessment tools and risk assessments. The care plans cover all areas of healthcare including mobility, pressure area care, maintaining a safe environment, continence, nutrition and mental and physical health. Where a risk has been identified, following assessment, a specific plan of care has been formulated offering full details for the action to be taken by staff to reduce the risk. Two files contained a fire risk assessment as both people smoke cigarettes; smoking management programmes are included in the care plan for maintaining their safety and a safe environment. Following a risk assessment a care plan has been developed for providing the equipment to a person to enable them to make hot drinks in the bedroom. A communication plan had been developed for a person whose first language is not English and contains details of non-verbal communications. The manager stated that some staff employed at the home are able to communicate with this person in their own language but went on to say that this person is able to communicate his needs to staff. Each plan included psychological assessments and included strategies for dealing with verbal and challenging behaviours. One person had a very detailed plan for supporting and assisting with the management of an anxiety disorder. Seventeen surveys completed by and on behalf of people living in the home indicated that they can make decisions daily about what to do and can do what they want to do during the day, evenings and at weekends. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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 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 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. JUDGEMENT – we looked at outcomes for the following standard(s): Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 13 YA 12,13,15,16,17. OP 10,12,13,15 Quality in this outcome area is good. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that due to the complexities and long standing mental health difficulties not many people wish to have further education or training, staff however were observed to be assisting people with budgeting and assisting with personal finances. Throughout the day many people were observed to be choosing their particular activity for the day and were being supported and encouraged by the staff to go to the local shops, pubs, and beauty salons. The manager stated that not many people visit the home on a regular basis although family and friend participation is encouraged. One relative visited during the morning and stated that she was a regular visitor and came often to see her family. One person spoke of them having a key to their bedroom, and the problems previously encountered with losing and misplacing the key, staff have assisted with this by providing a chain to secure the key on his person. Other people stated they did not wish to have a key. Staff were observed to be knocking on bedroom doors before entering and were observed to be assisting with choices and decision making in a manner which supports independence. Meals are prepared by the catering staff and served in the dining room. A choice of menu is available with people stating that they can have an alternative if the meal is not to their preference. One person stated the ‘food is good, sufficient and I can have a yoghurt or something else if I do not like the pudding’. The cook offered a good knowledge of the personal preferences of the people living at the home with the manager explaining the healthy eating options available. Nutritional needs are assessed on a regular basis with monthly monitoring of a persons weight recorded in the care plan. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA 18,19,20. OP 8,9,10 Quality in this outcome area is good. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each persons plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One care plan identified a person’s preference for a female carer for assisting with personal care interventions. An information board identifying the individual key worker for each person is in the main office with codes for the differing personal interventions that are Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 15 needed. The manager stated this is a reference point for monitoring personal care needs. People at the home all appeared to be well dressed and groomed. Times for rising during the morning were observed to be flexible with people rising at different times, the manager explained the different daily routines for the individuals. The manager was observed to be administering medication to people throughout the morning; she was discussing and supporting people with the procedure. All people have had a recent review of their medication; letters of the review are kept with the Medication Administration Record. The medication trolley is secured in the main office; temperature of the medication fridge is recorded daily. It is recommended that the minimum/maximum temperature be recorded to ensure that medications are stored in line with the manufacturers recommendations. Healthcare professionals are accessed when necessary; visits to and from professionals are recorded in the care plan. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 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 safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA 22,23. OP 16,18 Quality in this outcome area is good. The home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure has been recently reviewed and is displayed on the notice board, the manager stated that no complaints have been made recently. The manager and staff appear to have developed good relationships with people at the home, encouraging them to discuss concerns or worries both in the formal and informal settings. A bound book is used to record any complaints/concerns that are raised and includes the outcome and any improvements/ changes that may be needed as a result. Seventeen surveys completed by and on behalf of people living in the home specifying that they ‘knew who to speak with if they are not happy’ with some people indicating they would speak with the manager or their key worker. ‘ Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 17 The pre inspection questionnaire indicated that all staff have had adult protection awareness training, the manager and observation of the attendance certificates confirmed this. The care plans include information for staff of the interventions or distraction techniques to be applied where there may be incidences of physical/verbal aggression. The money kept by the home for safe keeping and assisting with budgeting is kept in a locked drawer in separate wallets. Individual recording sheets are used for each transaction with the person signing on each occasion. A lockable drawer is provided in each bedroom for the safe keeping of personal possessions if required. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): YA 24,30. OP 19,26 Quality in this outcome area is good. The home provides a physical environment that is appropriate to the specific needs of the people who live there. This judgement has been made using available evidence including a visit to this service. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 19 EVIDENCE: During the tour of the premises many of the bedrooms were personalised, the lounge and dining areas are well furnished, homely and comfortable. The dining room has recently benefited from being redecorated and provides a pleasant, bright area. The manager stated that plans are in hand for replacing the carpets in the corridors to a more suitable flooring material. All areas of the home were spotlessly clean; the staff responsible for the household cleaning must be commended on maintaining such high standards The laundry is situated in the basement of the premises and has the necessary equipment for dealing with clothing and linen. Hand wash facilities have been provided in all communal areas and at the point of the delivery of care. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 20 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 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): YA 32,34,35. OP 27,28,29,30 Quality in this outcome area is good. People who use the service report that staff working with them are very skilled in their role, and are consistently able to meet their needs. The service ensures that all staff receives relevant training that is focussed on delivering improved outcomes for people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were selected for inspection, only one file contained a criminal record bureau disclosure and two had proof of a person’s identity. The manager explained that the administrator assists with obtaining the Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 21 information and checks and that some of the information would be in the other office but she confirmed that all staff have had a criminal record bureau disclosures and identity checks had been carried out. Nursing registrations are filed separately for ease of reference and all appeared to be up to date. Two comment cards have been completed by the general practitioners involved with the home and specified that ‘, always a senior member of staff to confer with, staff have an understanding of the care needs, overall satisfied with the care provided to service users in the home’. Seventeen surveys completed by and on behalf of people living in the home indicated ‘staff always treat them well and listen and act of what they say’. Two relative surveys have been completed and indicated that in their opinion ‘staff have the right skills and experience to meet the needs of people’. The training and development requirements of staff are identified through the appraisal and supervision systems. Recent training includes first aid, food hygiene, health and safety, abuse awareness and challenging behaviour. Staff are encouraged to train to National Vocational Qualification levels 2,3 and 4 in care. Certificates and accreditations for training are included in the individual personnel files. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 22 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 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 23 YA 37,39,42. OP 31,33,35,38 Quality in this outcome area is good. The registered manager has the required qualification and experience, is highly competent to run the home and meets its stated aims and objectives. The manager, senior team, and staff at all levels have a good understanding of risk assessment processes and this is taken into account in all aspects of the running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Janet Morgan has been the registered manager of the home for approx 3 ½ years and demonstrated a sound knowledge and understanding of the client group and the difficulties experienced by some people with mental ill health. Her management style is one of openness and inclusion, supporting and involving people with all aspects of life at the home. She is well supported by the owner of the home. Staff and resident meetings occur on a regular basis with minutes kept of the content of the meetings. Satisfaction surveys are distributed to people living at the home on a six monthly basis. The last one in January 2007 has been analysed and action taken on the comments and suggestions received. Policies and procedures relating to the home are reviewed annually and updated where necessary. Weekly, monthly and annual testing of the equipment and premises are conducted with records kept. The fire risk assessment was last reviewed in April 2007. The security of the premises has been improved with the installation of electrically operated gates at the side of the property ensuring that people have safe access to the grounds. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 4 38 X 39 3 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chase Mental Nursing Home Score 3 3 3 X DS0000020796.V335796.R01.S.doc Version 5.2 Page 25 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. 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 2 Refer to Standard YA20 YA34 Good Practice Recommendations For the safe storage of medication it is recommended that the minimum maximum temperature of the medication fridge be recorded daily. A system should be implemented to ensure the personnel files for staff contain the specific requirements in regard to their proof of identity, written references and suitability to work with vulnerable adults. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Chase Mental Nursing Home DS0000020796.V335796.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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