This inspection was carried out on 12th March 2006.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
Chaseborough House Village Hall Lane Wimborne Dorset BH21 6SG Lead Inspector
Trevor Julian Unannounced Inspection 12th March 2006 10:00 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 Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chaseborough House Address Village Hall Lane Wimborne Dorset BH21 6SG 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) 01202 822908 Mrs Sally Ann Marshall Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17th November 2005 Brief Description of the Service: Chaseborough House is a care home accommodating a maximum of 16 older people. The premises are situated in a rural setting between Verwood and West Moors at Three Legged Cross, with local amenities including a pub, shops and village hall available within a short level walk. Accommodation is offered on the ground and first floor. The communal lounge and dining room are on the ground floor. A passenger lift operates to the first floor. There are twelve single rooms and two rooms registered doubles. All but one room has en-suite facilities, including seven rooms with baths, WC, and hand basins. The premises consist of a large converted family house set in its own grounds. The owners live in the adjacent property. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Sunday 12th March 2006 between 10:00 and 12:30. The purpose of the visit was to assess the key standards not covered during the previous inspection and to follow up on the requirements and recommendations from that visit. Information was gathered through discussion with the residents, visitor, staff and the owner; further evidence was gained from the examination of records and a tour of the premises. For the purposes of this report the terms service user and residents are interchangeable. What the service does well: What has improved since the last inspection?
The home continued to work towards meeting the National Minimum Standards. There was a process for quality assurance and the outcomes of those surveys were acted upon. The home had introduced a new medication administration system to improve reduce the risk of errors. The staff were still getting used to the system.
Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 6 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. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 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 Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 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): 3 Assessments were in place to ensure that residents were only admitted once the home verified that it could meet the individuals’ needs. EVIDENCE: During the previous inspection it was found that the home did not record a history of falls. During this inspection two files showed that the topic was now covered although in one case their was insufficient detail to identify any trends or triggers for those falls. All other recommended topics were covered. Two of the residents seen during the visit confirmed that assessments had taken place. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 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): 9 The home’s medication systems and procedures were being revised to ensure that medication was safely managed. EVIDENCE: The home had recently started a new system of medication using a monitored dosage system. Those staff using the system had been trained it its use. As a result medication system was not fully inspected as the staff were still familiarising themselves with the system. The home had installed a new medication storage cupboard. The home did have a receipt book showing items returned to the chemist. The remaining requirements and recommendations relating to medication are repeated for consideration at the next visit. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 10 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): Not assessed during this inspection. EVIDENCE: Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 11 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): 18 The home’s procedure on adult protection does not provide robust information and could lead to inappropriate responses to concerns raised. EVIDENCE: The home’s whistle-blowing policy included some information on adult protection matters. It was recommended that the procedure be reviewed and two specific policies produced. The previous recommendation is repeated. The home did have a copy of local adult protection guidance “No Secrets” Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 12 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): 25 The home provides the residents with comfortable surroundings but there are areas, which need attention. EVIDENCE: Since the last inspection several more radiators had been covered to reduce the risk of burns from hot surfaces. There was a generic risk assessment but this was not up to date. The remaining uncovered surfaces should be individually risk assessed as per Health and Safety Guidance. The residents and visitors said they found the home was comfortable and had been kept warm during the winter months. A new resident said she was very pleased with her room and that her family were busy bringing in her personal items to help her feel at home. The home is in a country setting and several people said they were looking forward to the spring when they could get outside to enjoy the garden. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 13 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): 29 The home’s recruitment procedure was not robust and could result in the employment of unsuitable applicants. EVIDENCE: The home does not have a high turnover of staff, consequently only one person had been recruited since the last inspection and the other file reviewed related to one person previously checked. The newest recruit had CRB and POVA checks in place before starting work, the other file still did not contain information about a completed CRB check. The application forms were not complete and there were unexplained gaps in employment history. Residents said they appreciated the care provided by Mrs Marshall and her staff. The visitor and residents said the staff were kind and patient and there were never any cross words from the staff. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 14 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 consults with residents and other interested parties to ensure that the home meets their expectations. EVIDENCE: Mrs Marshall undertakes two surveys a year to obtain the views of residents, families, friends and health visitors, about the standard of the service offered. The comments received are addressed individually. Several residents seen during the visit said that they confident that they were able to make suggestions and express their concerns as they arose. Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 15 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X 2 X STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24 Requirement Effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in meeting the aims, objectives and statement of purpose of the home. This requirement was first made 10th July 2002 and is repeated for the fifth time. Where pipe work and radiators are not guarded or have guaranteed low temperature surfaces, serious risks must be identified and as far as possible eliminated. This assessment must be pertinent to the individual(s) assessed and be written down. Previous time scale for action 6 March 2005. Pre employment checks as required by law must be undertaken prior to any staff working at the home. E.g. CRBs / POVA 1st checks. Records required by law in
DS0000026779.V286396.R01.S.doc Timescale for action 31/05/06 2. OP25 13 01/04/06 3. OP29 17 31/05/06 Chaseborough House Version 5.1 Page 17 respect of staff employed must be held in the home. E.g. proof of id. Previous time scale for action 31/1/06 During the recruitment process the registered person must ensure there are no unexplained gaps in employment history. 4. OP29 17 31/05/06 Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3. Refer to Standard OP3 OP7 OP7 Good Practice Recommendations The assessment should include information on the history of falls. The details recorded should be sufficient to identify trends and analysis. Every care plan should include a risk assessment. The care plan and risk assessment should pay particular attention to the prevention of falls. The care plan should be reviewed at least once a month and updated where appropriate. How the resident/ their supporter were involved in drawing up the care plan should be noted and the plan signed to show agreement where possible. Risk assessments for service users who self-medicate should include: A summary of the risks Who might be harmed Controls that should be put in place. These could include regular reviews, confirming service users have a lockable space and understand the risks their medication could pose to other service users. Handwritten details of prescribed medicines on the medicine chart should be checked and signed by a second competent person to confirm that all the details are correct. The date of starting individual packs should be recorded either on the pack or on the MAR chart to provide an audit trail and because some medicines e.g. eye drops have a limited life after opening. The manager should obtain a CD record book. The home should have an abuse policy / procedure specifically for staff at the home and include reference to the Protection of Vulnerable Adults List - how pre employment checks are carried out and of how staff may be referred. 4. OP9 6. OP9 7. OP9 8. 9. OP9 OP18 Chaseborough House DS0000026779.V286396.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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