Inspection on 19/02/07 for Chasefield House

This inspection was carried out on 19th February 2007.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chasefield House 26/06/07

Chasefield House 31/01/06

Chasefield House 09/04/05

Chasefield House 04/11/04

Chasefield House 26/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Chasefield House 888 Fishponds Road Fishponds Bristol BS16 3XB Lead Inspector Melanie Edwards Key Announced Inspection 19th February 2007 09:30 Chasefield House DS0000020329.V329790.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 Chasefield House DS0000020329.V329790.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 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. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chasefield House Address 888 Fishponds Road Fishponds Bristol BS16 3XB 0117 9653750 0117 9709301 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Michael Christopher Rogers Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To comply with the Staffing Notice dated 30/01/1995, amended 22/8/05 Manager must be a RN on parts 5 or 14 of the NMC register The Home may accommodate up to 15 persons aged 18 and over, who have learning difficulties and require nursing or personal care. 31st January 2006 Date of last inspection Brief Description of the Service: Chasefield is registered as a Care Home with nursing for 15 adults with learning difficulties. The house is situated in an urban location and can easily be accessed by car or bus. The nearby Fishponds Road high street is a busy shopping centre and has various social and community facilities. The house is a converted older property providing double and single rooms in three areas. There are two lounges, a dining room and a well-equipped workshop. The house has an extensive rear garden and vegetable garden, which residents can help maintain. The fees charged to stay at the Home range from £795 to £899.35 a week. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met seven of the thirteen residents living at the Home. Three members of staff were consulted about roles and responsibilities, training needs, and how they support residents. Staff were observed supporting the residents with their needs. A selection of records relating to the running and management of the Home were inspected. A sample of residents care records and care plans were reviewed. The majority of the environment was seen with the only areas not viewed being one resident’s bedroom. The Home was operating within the required conditions of registration set down by the Commission. The conditions of registration set out the type of care, the needs of residents, and numbers of residents who may stay at the Home. What the service does well: What has improved since the last inspection? What they could do better: All residents must have an up to date care plan in place that demonstrates how their needs are met. One resident’s care plan could not be located, despite considerable efforts to find it by the staff on duty. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 6 All residents care plans must be reviewed and updated on a regular basis to demonstrate how residents changing needs are met. Residents’ medication administration charts need to clearly state what dosages of medication residents are given. Staff should not cross out and alter dosages, but must re-write the charts if there have been changes made by the GP. This is to ensure residents are given the required amount of medication. When residents are prescribed medication to be given on an occasional basis, there must be guidance in place to advise registered nurses when to give the residents their medications. Where residents are administered topical creams and ointments there must be instructions written that set out how to administer the ointments or creams. Residents controlled drugs must be stored as is legally required in a locked cupboard, inside of a locked medication cupboard. All staff need to be trained in safe infection control practices and procedures. Specifically staff need to be wearing gloves when in direct contact with residents’ bodily fluids. Domestic staff should be wearing suitable protective aprons when cleaning the Home. An up to date fire safety risk assessment needs to be put in place for the Home to maintain the safety of residents’ staff and visitors. Residents day-to-day progress records of their health and general well being are now being written in individual large diaries. A significant number of entries have not being signed by the person who has written them. There are also large `gaps’ on each page. This means that records are not being written to the standard required in a Care Home for nursing. The records need to be written in a way that means they cannot be tampered with or altered at a later date. To make meal times a more enjoyable experience residents should be provided with salt, pepper, vinegar and other condiments at their table at mealtimes. 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. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being assessed, and residents feel satisfied with how their needs are met. EVIDENCE: To find out how effectively residents’ needs are being assessed the assessment records of two residents were reviewed. The staff team had completed assessments of the physical, mental health and social needs of each resident. There was also information recorded about the resident’s views of their care. Included in the assessments were the likes and dislikes of residents, and their choice of social activities. Residents spoke positively about how staff support them. Examples of comments made by residents included, ` the staff are very helpful and very friendly they are like a family,’ `the staff are helpful, I go to work and I enjoy it, sometimes the staff take me out ’, and, ‘the staff are alright ’. These comments help demonstrate residents feel satisfied with how their needs are met. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are a lack of resident’s care plans in place to be able to reflect how their needs are met. However residents are supported to make decisions and to take risks in their daily lives. EVIDENCE: To find out how effectively residents are being supported to meet their needs two care plans were requested for inspection. One residents care plan could not be located, despite considerable efforts to find it by the staff on duty. It is a matter of the highest priority that all residents have an up to date care plan in place that demonstrates how their needs are met. This must be addressed by the Home without delay. There was a personal profile completed for the resident whose care plan was available. This included the personal history of the resident, information about their physical and mental health history, as well as a record of the important Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 10 people such as family and friends for the individual. There was also a plan of care for the resident to address their physical, mental, and social needs. The care plan generally aimed to promote the independence of the person in their daily lives. There was evidence written in the records that residents had been consulted in the care planning process. However the care plan had not been reviewed or updated on a regular basis. This is required so that the Home can demonstrate how residents changing needs are met. The staff were assisting residents with their needs in a sensitive and patient manner. Staff were also observed talking to residents in a warm manner. This helps to demonstrate that residents are well supported by staff. Both residents records that were requested did include risk assessments addressing any potential risks the resident may face, and any risk behaviours they may exhibit. The risk assessments set out the preferred approaches staff needed to follow to support the residents. There was information written in the resident’s records that showed staff support residents to maintain independence in their daily lives. Residents said that they go out with staff in the lease car on a regular basis for trips out to the local community. One resident said that they attend a local bingo session on a regular basis. During the inspection a small group of residents went bowling at a local bowling alley. Members of staff took small groups of residents out to the shops and for a coffee in the morning and the afternoon. This is evidence that demonstrates how residents are supported and encouraged to take some risks as part of an independent life style. Staff were observed consulting residents about their preferred meal options for the days meals. This is an example of how residents are supported to take an active role in the day-to-day running of the Home. Residents were getting up at different times during the morning, which helps to demonstrate how their choices and different preferences are respected Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 Quality in this outcome area is good. Residents are well supported to take part in a range of appropriate leisure activities. They are further supported to be a part of the community and to have opportunities for personal development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 12 As already referred to in the report, residents go out with staff in the Homes lease car on a regular basis on regular trips out to the local community. One resident showed the inspector a book they had bought at a nearby shop on a visit out to the shops with a member of staff. One resident said that they regularly visit their boyfriend who lives near the Home. They said that staff drive them there, and they see each other several times a week. This is a good example of residents being supported to maintain close contact with significant people outside of the Home. A massage therapist visits the Home on a regular basis giving one to one massages to residents. One resident said that they attend education classes on a regular basis and they took part in cooking classes. Last year all residents who wanted went on a holiday. Two residents showed the inspector photographs of the recent holiday to Brixham. Both residents said they had had a really good holiday. There was information recorded in the two residents records that confirmed they regularly take part in a range of social and therapeutic activities. A copy of the current menu was reviewed to find out what sort of meals residents are provided with and if they are offered choices. There was a range of dishes recorded as being available for each day. There was evidence seen that demonstrate residents likes and dislikes are included when menus are planned. There was a varied choice of meal options available for the residents. Meal options included a range of traditional, nutritional meals. Three of the residents said that the food at the Home was good. A sample of one of the lunchtime meals options was tasted. The choices were sausage, egg, chips, and beans, or ham, peas and boiled potatoes. The meal was tasty, and satisfactorily cooked. However the mealtime would have been enhanced for residents if they had been provided with condiments, including salt, pepper and vinegar on their tables. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. 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. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are being supported with their needs in the way preferred by them, and their needs are being met. Residents ’ medication is not being stored administered and disposed of safely. EVIDENCE: Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 14 There is a record kept in residents care records of the physical health needs, and appointments (see also standard 6). This is a record of the residents’ last optician, chiropody, dental and G.P appointments. This helps to demonstrate that residents’ health care needs are met. As also referred to in the report, there was written evidence in the residents care records which showed the preferred day to day routine of the residents and their particular likes and dislikes. This helps to demonstrate how residents are being involved in the planning of their care. The plan of care that was reviewed set out the preferred manner in which to assist the resident to meet their health and social needs. Staff were talking with the residents in a relaxed manner and residents and staff have built up close trusting relationships. The procedures for the administration storage and disposal of medication were checked to monitor if there are safe systems in place. Medication was stored in the staff office in a locked wall mounted metal cabinet. However the stock of residents controlled drugs were not being stored as required in a locked medication cupboard, in a locked cupboard. The medication administration charts of four residents were read in detail. The charts were legible and contained the signature of the dispensing member of staff, as well as the reasons for any omissions. However there were entries on resident’s medication administration charts where staff had crossed out and altered dosages, and had not rewritten them. Alterations in the amount of medication residents require must be clearly written and there should be staff signatures and dates to confirm when dosages have altered. This is to ensure the safety of the resident when staff administer them their medication. There is currently no guidance for staff to follow, to know when to administer residents prescribed medication that is only given on an occasional basis. This guidance is necessary so that residents are administered the medication they may require for their health and psychological needs. A significant number of administration charts did not include guidance information when residents are being administered topical creams and ointments. This information is required so that residents’ creams and ointments are administered as prescribed. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is adequate. Residents will be supported to make complaints about the service. Also there are systems in place to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints record book was not reviewed on this inspection, as it could not be located. However residents said that they would talk to any of the staff if they did want to make a complaint, and they said staff would sort things out for them’. There are residents meetings held, and residents are encouraged and supported to set an agenda for the meetings. This is also a good opportunity for residents to complain if they need to. The member of staff who ran the last residents meeting said that they had spoken to residents about how they can complain, and explained what they need to do if they wish to make a complaint. There are procedures and guidance information on the topic of ‘ the protection of vulnerable adults from abuse’. This helps to protect vulnerable adults who live at the Home, if staff can access the necessary information to ensure their protection. The majority of the staff have attended recent training to help them better understand issues around the protection of vulnerable adults from abuse. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is generally suitable for their needs and lifestyles, promotes their independence, and is clean, hygienic, and generally satisfactorily maintained. EVIDENCE: The Home is set in its own grounds off the Fishponds Road in the Staple Hill area of Bristol. The garden looked satisfactorily maintained and there are seats and an area where residents can sit in warmer weather. The Home looked clean and tidy in the areas that were viewed. However there is clearly a need for a programme of redecoration to be undertaken, as the decoration looks worn and tired in a number of rooms. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 17 There is wheelchair access to the Home and the gardens. There are adaptations in place to assist residents and visitors with disabilities throughout the Home, however there is no lift access to the first floor. The lack of lift access to the first floor means some residents must climb stairs to get to their bedrooms. There is a dining room in the basement and two lounges, one of which is a designated non-smoking lounge. Residents were observed sitting in the lounges and dining room, looking very relaxed and comfortable in their surroundings. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. Toilets are situated in accessible parts of the Home near to communal areas and bedrooms. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a sufficient number of competent, qualified staff. EVIDENCE: The recruitment procedures were only partly reviewed on this inspection. Aspects and Milestones Trust have moved evidence of staff Criminal Records Bureau Checks back into the Home for all staff, from its head office. However staff references were not available. These records may be requested at the next inspection. The training records of one registered nurse and two support workers were reviewed to find out if staff are provided with good training in matters relevant to residents range of needs. There was evidence that staff had attended relevant study days in the previous twelve months. The staff spoke positively about recent study days they had been able to attend. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 19 There was information in the staff training records that showed staff had attended an induction programme on commencing employment. The staff meetings minutes record was looked at. These showed staff meetings were recorded as having taken place on a regular basis and staff are consulted about a range of relevant matters related to the day-to-day running of the Home. Staff also reported that there are regular staff meetings taking place in the Home. The staff duty record for February 2007 was reviewed to find out how many staff are on duty at any time to support residents with their needs. The number of catering and domestic staff was not reviewed at the inspection. The Home is registered as a Care Home providing nursing care. This means there is a registered nurse specialising in caring for people who have learning disabilities on duty twenty-four hours a day. The number of staff on duty is between four staff for the morning shift, and at least three staff for the afternoon shift. Two members of staff work a shift at night. Based on the evidence seen during the inspection, the number of staff on duty is sufficient to meet residents’ needs. There was a small amount of staff sickness recorded for the time period reviewed. The Home aim use regular ‘bank’ staff to make up any shortfalls. Staff were talking to residents on a one to one basis, and sitting with them in the lounges, residents looked relaxed and comfortable to approach staff and engage in conversation with them. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. 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 home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41,42. Quality in this outcome area is adequate. Residents’ benefit from a more stable Home, and by the recruitment of a new manager. Residents and staff health and safety is only partly protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Rattigan is a qualified learning disabilities nurse. Her career record shows that she has a number of years of experience working with residents who have leaning disabilities. She has applied to be registered with the Commission. As mentioned previously in the report there are regular residents meetings where residents can express their views about what they feel matters. This Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 21 helps demonstrate that residents feel confident and can express their views in the Home. The Home ensures records are kept in a locked metal cabinet in the office. The residents’ care records, and the records that were seen relating to the running of the Home were satisfactorily written, legible and in reasonable order. This helps to demonstrate residents confidentiality is being protected, and also that Ms Rattigan is ensuring that records required for the effective running of the Home are in order. However each resident’s progress record of their health and general well-being is now being written in individual large diaries. A number of the entries are not being signed by the members of staff writing them. Also there are large `gaps’ on pages. This means that records are not being written to the standard required in a Care Home with nursing. Records need to be written in a way that means they cannot be tampered with at a later date. The monthly monitoring visits of the Home that must be carried out by a representative of The Trust are being undertaken as required by law. There are records of these visits being sent to the Commission. The records that have been seen, demonstrate that the designated individual responsible for the visits spends time consulting with residents and their representatives and observing staff. The environment looked generally satisfactorily maintained, however as previously mentioned there is clearly a need for a programme of redecoration to be undertaken, as the decoration looks worn and tired in a number of rooms. Staff are provided with regular training in health and safety matters including first aid, and moving and handling practices. This should help protect residents’ health and safety if staff are knowledgeable and well trained. All staff also undertake food hygiene training to ensure they maintain their knowledge of good food safety practices. However all staff must be trained in infection control procedures. This is because one member of staff failed to wear gloves when in direct contact with a resident’s blood and domestic staff did not wear suitable protective aprons when cleaning the Home. The fire logbook record was checked and showed the required weekly and monthly tests of the fire alarms and the fire fighting equipment were being carried out and were up to date. However there is currently no fire safety risk assessment in place for the Home. An up to date fire safety risk assessment needs to be carried out of the Home to help to maintain the safety of resident’s staff and visitors. Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 22 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. 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 3 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 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 N/A 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 1 X 3 X 3 X 3 1 X Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement All residents must have an up to date care plan in place that demonstrates how their needs are met. All residents care plans must be reviewed and updated on a regular basis. Residents controlled drugs must be stored in a locked cupboard, in a locked cupboard. All staff must be trained in infection control procedures: Specifically staff using gloves when in direct contact with residents’ bodily fluids, and suitable protective aprons when cleaning the Home. Where residents are administered topical creams and ointments there must be instructions setting out where and how to administer the ointments or creams. There must be an up to date fire safety risk assessment carried out of the Home. Timescale for action 26/02/07 2. 3 4 YA6 YA20 YA42 15. (2)(b) 13. (2) 13. (3) 19/03/07 20/02/07 19/03/07 5 YA20 13. (2) 20/02/07 6 YA42 23.4c(v) 19/03/07 Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 24 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 YA17 YA41 Good Practice Recommendations Provide residents with condiments at their table at mealtimes. Residents’ daily progress records should be written in accordance with Nursing and Midwifery Council Guidelines Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Chasefield House DS0000020329.V329790.R01.S.doc Version 5.2 Page 26 - 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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