Inspection on 22/04/08 for Chasedale

This inspection was carried out on 22nd April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chasedale 10/02/10

Chasedale 21/01/10

Chasedale 27/10/09

Chasedale 28/01/09

Chasedale 29/10/07

Chasedale 02/11/06

Chasedale 02/02/06

Chasedale 20/06/05

Chasedale 06/01/05

Chasedale 11/08/04

Chasedale 09/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Chasedale Tynedale Drive Cowpen Estate Blyth Northumberland NE24 4LH Lead Inspector Suzanne McKean Key Unannounced Inspection 22nd April 2008 09:00 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 Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chasedale Address Tynedale Drive Cowpen Estate Blyth Northumberland NE24 4LH 01670 - 365997 01670 365732 chasedale@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd 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) Manager post vacant Care Home 60 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (10) of places Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 10 2. Dementia - Code DE, maximum number of places: 50 The maximum number of service users who may be accommodated is 60. 29th October 2007 Date of last inspection Brief Description of the Service: Chasedale Nursing Home is a two storey, purpose built facility of traditional brick build and tiled construction. It is situated on the edge of a large residential estate approximately two miles from the centre of the town of Blyth. The home is well served by public transport. The home has a car park to the front from which there is level access to the main entrance. There are grassed sitting areas, which are accessible to, and for the use of, residents and visitors. The home is registered to provide care to 60 persons 10 of which are the category of old age requiring nursing care and the remaining 46 under the category of dementia care (nursing). The home charges fees of between £380.42 and £400.78 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Summary: This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 29th October 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on date 22nd & 29th April and on 7th May 2008. There was also a visit by the Commission for Social Care Inspection pharmacy advisor. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? At the last inspection 22 requirements were made, 16 of these have been met. All of the outstanding 6 have had work carried out to meet them but some improvements are still required. The following improvements have been made:• The service user guide and the statement of purpose have been improved to show the way the service is being provided. • The home now promotes and makes proper provision for the health and welfare of the residents. • Residents are now being supported to make choices in their day-to-day lives, which is documented. • The residents are being supported to live fulfilled and active lives according to the wishes and abilities. • The residents receive an adequate diet according to their choices and needs and the catering staff are being given training to give them the skills and competencies to fully fulfil the role. • The way complaints are managed in the home has been reviewed to ensure that they are managed effectively. • The staff who are in charge of the home for periods have been given training in the safeguarding procedures and are now confident in this area of practice. Agreed safeguarding strategies are now being followed to ensure that the safety of the residents is maintained. • Health Protection Unit advice is being followed in relation to control of infection. • Staffing levels have been reviewed to ensure that sufficient staff are provided to meet the needs of the residents, and the home now employ staff who have the skills and experience to ensure they can meet the needs of the residents. • The provider has in place a system for evaluating the quality of care in the home. • The home makes sure they are acting in the best interest of the residents when managing personal allowances on their behalf. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 7 • • The registered individual ensures that the staff follow the company’s health and safety policies including the completion detailed risk assessments. A fire risk assessment has been completed and is available in the home for staff to use. 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. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 8 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 Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessment processes ensure that residents are fully assessed prior to being offered a place and can be confident that their individual needs will be met. EVIDENCE: The home has a statement of purpose and service user guide, which combines the company’s pre-printed brochures and the information, which relates specifically to the home and the service they provide. This is in sufficient detail to describe the service the home provides particularly within the different units. The care plans all have pre-admission assessments, these had been carried out by either the manager or by a senior member of the staff team. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 10 The residents also have a care management assessment, which is provided to the home on admission. An individual care plan is produced from these documents. The home is not registered for, and therefore does not provide, intermediate care. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good care is given to the people living in the home but care planning does not always follow a person centred approach to ensure diversity of need is fully supported. Medication systems are good but are not always correctly followed by the home, which may put people at risk of harm. EVIDENCE: All residents have a care plan which includes an assessment of their needs and a plan of how these should be met. Four Seasons documentation includes risk assessments for prevention of falls, wound care, and moving and assisting as well as assessment tools for clinical areas such as continence promotion. These had been completed to an adequate standard, which reflected the health needs of the residents. The care plans were up to date and contantained the information to assist the staff to care for the resident. One in particular contained very well constructed care plans with advice from the NHS Behavioural team, which had been used to good effect. Some plans are less Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 12 detailed about the ways in which the staff could assist the resident when they become agitated or upset. On observation the staff obviously had good understanding of how to intervene at these times but this was not always clearly identified in the documentation. There are plans to further improve the documentation in the home to make them more person centred. Improvements are also planned in the way that the social needs of the residents are assessed and planned to make sure that the people living in the home live fulfilled lives taking into account their level of dependency. This is particularly challenging for the people living in the home who have a dementia. There is an assessment to look at residents’ food and fluid intake. The record of fluid intake was poorly managed on the first visit however this had been significantly improved by the second visit to clearly show the support that was being given to make sure that they were being adequately hydrated. Staff were confident when giving care and are now supported by effective training in areas such as moving and handling. Additional hoists have been recently purchased and these are being adequately maintained. Additional equipment such as slings and slide sheets were readily accessible for the staff and they were being used effectively during the visits. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the company of the staff. The company medication policy is comprehensive and clear but has not been consistently amended to ensure that each unit has a copy of unified and up to date guidance on medicines. Out of date documents have not been removed and this may confuse staff as to what is expected of them. Staff do not always follow best practice guidance when giving medicines to people living in the home. This means that people living in the home are not always protected from medication errors or the risk of infection. All hand written entries on medication charts should be signed, dated and witnessed to reduce the risk of mistakes when copying medicines information. Most medicines in the home are stored safely but improvements in the monitoring of refrigerated storage is required to make sure that medicines are being stored correctly and are safe to administer. Secure storage for medicines awaiting disposal must be available to ensure no mishandling or theft. The staff were friendly toward the residents and were attempting to engage them in conversation. They have a good knowledge of the needs of the people Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 13 living in the home and the nursing staff are giving good direction and leadership to help them in the day-to-day delivery of care. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are well supported to live satisfying lives in line with their abilities and according to their cultural, social, religious and recreational interests and needs. EVIDENCE: Some residents described the ways they are encouraged to take control of their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. Staff confirmed that they assist residents to make choices about how they spend their day. There is a new activities co-coordinator in the home who has only been in post for a short time. However she has already made significant changes to the activities programme. She has introduced a programme of monthly group activities for example a visiting performer and a clothing party. She has also now met with each of the residents individually and developed a weekly plan for each of them based on their preferences, needs and abilities. There is documentation in place to show all of the social activities a resident has Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 15 participated in and a judgment of their level of enjoyment of it. This will allow her to consider if the activity is offered again or if an alternative option should be sought. Residents are able to choose whether or not they are involved in any activity. The way that the level of enjoyment is assessed also makes it possible for staff to make decisions for those who are not able to express tier views. There are weekly domino cards organised to generate money to fund some of the activities as well as monthly raffles. Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives are given information within the residents’ guide about visiting arrangements. Residents said they were satisfied with the arrangements for visitors and that staff welcome them. During the visit the food being served looked well presented and was at the appropriate temperature. The residents said the enjoyed the food and during both visits they cleared their plates. An example of resident’s comments was one who said, “there is always lots to choose from” and “ the food is lovely”. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good complaints and protection of vulnerable adults policy in place, which is well managed and give residents the opportunity to have their concerns dealt with and their safety maintained. EVIDENCE: The complaints procedure is available in the service users guide and a copy is available at the front entrance and is displayed in the home. The records of the complaints were examined. There have been no complaints received since the last inspection but the process of how they would be managed is clearly identified in the homes policies and the manager was familiar with the process. Residents and relatives spoken to understood how to make a complaint, and could identify the way this would be dealt with. Although two relatives had raised concerns in the past they were now happy with the way care their relative was now receiving. Some have been given protection of vulnerable adults training both as part of the in-house training package and from outside organisations. The home has written guidance in place regarding the protection of vulnerable adults through detailed policies and procedures. These are included in the induction training and ongoing in-house training. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 17 Staff confirmed that they knew about the guidance and could identify the action they would take if they were made aware of or had any concerns regarding this issue. The manager works within the safeguarding frameworks and is familiar with her responsibility in these processes. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the standard of cleanliness and décor has improved, the environment is poorly designed to accommodate the needs of people with dementia. This may add to people’s confusion and disorientation. EVIDENCE: There have been significant improvements the hygiene standards and the maintenance of the home. There were no offensive odours throughout the home. However, although the redecoration programme has been started it has not yet been completed, and there were no working sluices disinfectors in the home although there are three in situ. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 19 Twenty eight bedrooms have been redecorated and the carpets replaced as necessary. Corridors on the first floor were being decorated during the visits and the carpets are to be replaced once this has been done. The bathroom areas were clean but have not yet had the work carried out that is planned. The plans are for the shower rooms to be made into “wet rooms”. Also the bathrooms are to be redecorated new assisted baths put in where necessary and curtains or blinds put in place to protect the privacy and dignity of the people living in the home. The work to the shower rooms had been started on the second day of the visit. The dining rooms have been redecorated and they were well presented with tablecloths and condiments available. The rooms were clean and the domestic staff were observed deep cleaning the furniture in the afternoon which is now part of their regular cleaning programme. The domestic staff are now able to carry out their duties fully as they now have available the necessary cleaning programmes and equipment. They maintain good records of the work they carry out so that it can be audited. The laundry is clean and well organised and the staff understand the way to minimise the risk of cross infection. There is hand washing facilities, liquid soap and paper towels available as well as gloves and aprons. There has been a large amount of linen purchased and there is now sufficient amounts to make sure that any old or worn items can be disposed off. None of the three sluice disinfectors are working and have not been for at least five months before the last key inspection, so have now been out of action for at least eleven months. An immediate requirement was issues with regard to this on the last visit on 7th May 2008 for the home to have an operational sluice on each floor. It is not safe for the home to operate without an adequate means of ensuring that the equipment can be cleaned between uses. This is not an exhaustive list of the work that has been carried out or that which remains, but it is an overview of what we found. The manager is aware of the outstanding issues and has an action plan of what action will be taken. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are adequate to meet the range and diversity of needs of the people using the service. EVIDENCE: Staff recruitment and selection records were complete including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. There have been changes to the staffing skill mix resulting in more registered mental nurses on the team. It is appropriate for the staff team to have different skills. However, the complexity of the residents needs means that there is an increased need for a highly skilled staff team. This change has improved the way the care is being planned and it is now being requently reviewed. This has reduced the risk of untoward incidents occurring and make sure the residents have their mental health needs met. The staffing rota’s showed that there the number of periods when staff sickness and holidays results in periods of insufficient numbers of staff on duty has reduced. Care staff are now working fewer additional hours to those they Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 21 are contracted for, and there are fewer times when they are asked to cover at short notice. Relatives spoken to said that they were now less concerned about the number of staff on duty and were more confident about the way the home was being staffed and run. All new staff have been given moving and handling training and although a few of the existing staff need updates these are very few and they have been organised for the near future (dates available). All of the nurses have received Safeguarding / Protection Of Vulnerable Adults training. This was provided as an internal training programme, however external training has been arranged from an external training organisation in June, July and August for all staff. Not all of the care staff have had safeguarding training and this is to be arranged. Fourteen of the staff have first aid training so there can be a trained person on each shift. All of the kitchen staff have had NVQ 1 training in Food handling and hygiene and are now doing level 2. The manager is has a training programme in place to address the gaps in skills as not all of the care staff have had specialist dementia training. , Training is planned in dementia care mapping, and challenging aspects within mental health and dementia. Staff have also been offered other in house training opportunities including pressure area care and catheter care training. The staff are encouraged to undertake National Vocational Qualifications (NVQ 2) once they have had their induction training. Since the last inspection a number of them have registered for it. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is now consistent and effective and offers leadership to the staff; this improves the life of the people living in the home and protects them from harm. EVIDENCE: The new manager has now been in post since the last key inspection in October 2008. She is an experienced care home manager was previously working in another of the companies homes and was the registered manager. There is a deputy manager in post and the nurses work predominantly in particular units within the home. This is so that they can be confident that they Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 23 are familiar with the needs of the residents and offer a good level of consistency. The leadership in the home both in the way the care is being delivered to the residents and in the way the home is organised has improved and now all staff are confident in their work and are well supported. This includes the organising of training, staffing and supervision and ensuring that the home was being maintained and equipped adequately. During the visits to the home the residents were settled and seemed to be content. The staff were being clear leadership in what they were expected to do and were more focused on the needs of the individual residents rather on the work as tasks. The staff work hard and they said that they now felt that they were being well supported. Relatives spoke to were complementary about the staff and were now less concerned about the numbers of staff on duty and how busy they were. They said that although sometimes call buzzers were not being responded too immediately they were now been answered in a reasonable time. Discussion with the relatives suggested that they felt that the changes to the qualified staff has resulted in an increase in the communication. Personally allowances are well managed and are audited both in-house and from the company senior administrator. The records held in the home were up to date and detailed and there were receipts for purchases made on behalf of the residents. The staff, residents and relatives were now very confident that their views were listened to and valued by the Manager. The annual quality assurance assessment (self assessment) was returned to Commission for Social Care Inspection and this reflects the standards of the service being provided and the way the manager plans to improve it further. The internal quality assurance mechanism (TAP audit) has been reviewed and the manager is using it to plan her improvement strategy and to demonstrate to the company the resources she requires to achieve this. Chasedale DS0000000508.V362923.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Each resident must have an up to date care plan containing sufficient information for the staff on the care to be provided. Outstanding since 01/12/07 The registered person must ensure that medication is always administered according to current best practice guidelines. Outstanding since 01/12/07. The home must undertake a programme of redecoration, recarpeting and re-placement of furniture in the communal areas and bathrooms. Outstanding from 01/07/07 The home must undertake a programme of redecoration, recarpeting and replacement of furniture in the bedrooms. Outstanding from 01/07/08 The home must have adequate control of infection practices including the ability to safely clean and disinfect items of DS0000000508.V362923.R01.S.doc Timescale for action 01/08/08 2. OP9 13 01/08/08 3. OP19 16 01/12/08 4. OP19 16 01/12/08 5. OP26 13 15/06/08 Chasedale Version 5.2 Page 26 equipment such as commode pots and urine bottles. This must include a hot wash steriliser unit on each floor. 6. OP30 19 The home must provide training to ensure that the staff working in the home have the skills and experience necessary for the work they do. Outstanding since 01/01/07 01/12/08 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 OP31 Good Practice Recommendations The manager should submit her application to Commission for Social Care Inspection for registration. Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Chasedale DS0000000508.V362923.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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