Inspection on 19/08/05 for Chaseside Residential Care Home

This inspection was carried out on 19th August 2005.

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.

Other inspections for this house

Chaseside Residential Care Home 14/09/06

Chaseside Residential Care Home 03/05/05

Chaseside Residential Care Home 09/02/05

Chaseside Residential Care Home 02/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Chaseside Residential Care Home St Georges Square St Annes Lancashire FY8 2NY Lead Inspector Denise Upton Unannounced 19 & 23th August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chaseside Residential Care Home Address St Georges Square St Annes Lancashire FY8 2NY 01253 724784 01253 838936 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Philip Tandy Mrs Denise Hayes Care home only 24 Category(ies) of OP Old Age (23) registration, with number PD Physical Disability (1) of places Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home may accommodate 23 service users in the old age (OP) category and one named service user in the physical disability (PD) category. Date of last inspection 3rd May 2005 Brief Description of the Service: Chaseside residential care home is currently registered to accommodate up to 23 older people and one named adult in the physical disability category who do not require nursing care. The home is owned by Mr Phillip Tandy, however as Mr Tandy is not in day-to-day control of the home, as a requirement of registration, a registered manager with the appropriate experience and qualifications must be appointed to undertake day-to-day management responsibility. Recently a new manager was appointed at Chaseside Care Home and this person has now been registered with the Commission For Social Care Inspection. Chaseside Care Home is located in a quiet residential area of St Annes but in close proximity to the main shopping centre, a local park and community facilities and resources.The home is arranged over three floors with the majority of service users accommodated in single bedroom accommodation. Only one bedroom is for shared occupancy. Communal areas of the home consist of two lounges, a separate dining room and combined lounge/dining area. Although bedroom accommodation does not provide an ensuite facility, bathing and toilet facilities are sufficient in number, conveniently situated and provided with appropriate aids to promote independence. A passenger lift is provided. There is a lawn area with flowerbeds to the front of the building and a patio area to the side with tables and seating. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of a day and part of a second day and in total spanned a period of almost eleven hours. The inspector spoke with the home’s registered manager, deputy manager and individual discussion took place with two members of the care staff team. Individual discussion also took place with the four service users who were ‘case tracked’ during the course of the inspection and four relatives/friends who were visiting. Case tracking involves looking at these residents individual care files to make sure that the correct information is recorded and that the individual care plan, that tells staff what the resident can do for themselves and what help may be required, is reviewed on a regular basis and kept up to date. Informal individual discussion also took place with several other residents in various communal areas of the home or in their individual bedroom accommodation. A number of records and policies and procedures were examined and a partial tour of the building took place. What the service does well: Chaseside Care Home has a group of staff that work well together and are keen to provide a high quality service to residents who live at the home. Residents spoken with felt well cared for and stated they were very pleased with the individual care and support received. One recently admitted resident said that she was ‘very happy with the staff’ who were ‘all very kind and helpful’ and another resident reported that staff were ‘excellent’ and she enjoyed the ‘freedom and flexibility’ of living at the home. It is clear that there is a good relationship between residents and staff that help service users feel comfortable. There are good systems in place to find out what residents and their relatives/friends feel about how the home is meeting individual needs and requirements. This encourages residents to have their say and helps bring about changes in the home. Chaseside Care Home also has been awarded the ‘Investor In People’ award that is a nationally recognised quality assurance system and only awarded when a home has achieved a certain standard. All service users spoken with were very satisfied with their individual bedroom accommodation that is furnished in a style to suit the individual resident. Mealtimes and the quality and variety of the food served are also very important and residents spoke highly of the meals and dining arrangements. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 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 standard(s) 1 & 3 The home’s Statement of Purpose and Service Users Guide still require further amendment in order to meet requirements and recommendations. Once this has been completed, the Statement of Purpose and Service User Guide will provide service users and prospective service users with excellent information of the services and facilities the home provides to enable an informed decision about admission to the home. The pre admission assessment form to identify what the prospective service user can do well and what help may be required has also been redeveloped and expanded since the last inspection. This is to ensure that the written pre admission information is in sufficient detail to establish if current strengths, needs, wants and wishes could be met at the home. EVIDENCE: It was identified in the last inspection report that the home’s Statement of Purpose and Service User Guide required further inclusions in order to meet in full, the requirements of Regulation and the recommendations of the Standard. Whilst some amendments have been noted to the Statement of Purpose, a small number of further inclusions are still required. Likewise, at the time of Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 9 this inspection, the Service User Guide was incomplete and further information is required to be incorporated to ensure that the document meets requirements. Once completed both updated documents should be made available to all current and prospective service users. It is recommended that reference be made to Regulations 4 & 5, Schedule 1 of the Care Homes Regulations 2001 and Standard 1 National Minimum Standards–Care Homes For Older People to ensure compliance. In order to ensure that service users are only admitted to the home if their health, personal and social care needs can be met, the registered manager undertakes a pre admission assessment of current strengths and needs to determine if the level of care and support required can be provided. The information obtained through this process is now recorded in greater detail to provide a more holistic account of the service user’s requirements however this process could be expanded still further. The ‘in-house’ assessment can also be supplemented by a health and social services assessment of current needs and requirements. In the main this collated information provided the basis of the initial care plan. Staff spoken with were clearly aware of the strengths and needs of the two most recently admitted service users who were both very pleased and satisfied with their admission to the home and how this had been achieved. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7 & 9 Although there remains a consistent care planning and risk assessment process in place, the information is not always recorded or recorded in sufficient detail to adequately provide staff with the written information they need to ensure that the requirements of the individual service user is fully met. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. EVIDENCE: It is usually normal practice for all service users at Chaseside Care Home to have an individual plan of care based on current assessed strengths and needs that is developed from the initial assessment process. However in respect of one fairly recently admitted service user there was no evidence of a formal care plan ever having being developed or relevant risk assessments being undertaken. Discussion with the service user and her daughter confirmed that the pre admission assessment process had been undertaken and staff were in practice, Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 11 addressing her strengths and needs very well however information sharing in respect of fulfilling strengths and needs was dependent on verbal communication rather than a formal approach to instruct and guide staff. Whilst there is no suggestion that the requirements of this service user were being compromised, with the service user and her daughter both extremely positive in their comments of the care provided stating that the service had exceeded their expectations, never the less all service users must have a formal, detailed and comprehensive care plan in place. In addition, formal risk assessments must be undertaken when a specific risk is identified with outcomes incorporated in the care plan. Care plans and some risk assessments were available in respect of the remaining service users however these should be further expanded and developed to ensure that they provide a full and accurate account of current strengths, needs and requirements. It was evident that a number of informal risk assessments had also been undertaken and measures put into place to minimise the risk, however the outcome of the individual risk assessment was not necessarily incorporated in the plan of care. Since the last inspection there was no evidence that care plans had been formally reviewed. All care plans should be reviewed on at least a monthly basis with outcomes recorded, discussed with the individual service user and signed by the service user wherever possible. All service users spoken with were very pleased with the individual care and support provided by staff at Chaseside Care Home and confirmed that they felt safe and secure. One service user said she enjoyed the ‘friendship’ of the staff who often spent time with her on a one to one basis and described the staff as ‘all very good, helpful, lovely and more like friends’. The standard associated with medication was not fully assessed at this inspection, however a number of medication administration records were examined that were correctly completed. The recording of administration has significantly improved over the last eight months since the appointment of the new registered manager and staff are now proficient through training and instruction to ensure the records and medication are accurate. All service users who have capacity and wish to do so are enabled to self medicate within a risk assessment framework. It is important that the formal individual risk assessment in respect of self-medicating is readily available and kept with the self-medication disclaimer. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 & 15 Service users are encouraged to maintain contact with their family and friends to ensure these relationships are sustained. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users taste and choice. EVIDENCE: Service users and their family and friends are informed of the home’s policy in respect of visitors at the time of admission and provided with written information in the Service User Guide. As observed at the time of inspection, it was clearly evident that service users can entertain visitors of their choice at a time to suit them either in a communal area of the home or individual bedroom accommodation. Visitors spoken with who visit their relative or friend at Chaseside on a very regular basis all stated they were always made to feel welcome, offered refreshments and had a good relationship with the staff group. It was also reported that staff respected their privacy when visiting relatives and that service users were able to exercise individual choice with routines kept flexible and varied to suit service users preferences. Meals and mealtimes at Chaseside are given high priority with a varied and balanced menu provided that is designed round the known likes and dislikes of Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 13 service users living at the home. Service users are encouraged to become involved in menu planning and say what meals they would like to be served throughout the various seasons of the year. There is a choice of main course and sweet at the lunch and evening meal and service users can choose to either have breakfast in their individual bedroom or alternatively eat in the dining room. In addition, a substantial supper is also made available. Specialist diets in respect of medical needs are provided and diets in respect of religious or cultural requirements could also be accommodated. Service users spoken with were all positive about the variety and quality of the meals served with one service user describing the food as ‘very good with a good choice’. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 & 18 The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff have a good knowledge and understanding of adult protection issues, which protects service users from abuse. EVIDENCE: The complaint procedure at Chaseside Care Home is compliant with requirements and identified in the Statement of Purpose, Service User Guide and displayed in individual bedroom accommodation. During the course of the inspection, service users and relatives/friends spoken with were very positive about living at the home and raised no complaints. However service users confirmed that they were aware that the home had a complaint procedure and stated they felt confident that any concern would be taken seriously and the matter addressed. Chaseside Care Home also has available a variety of policies and procedures observed at inspection for the protection of service users. These include an Adult Protection Policy based on the `No Secrets` documents and a whistle blowing policy to protect service users from abuse or discrimination. Further policies were evidenced in respect of physical aggression, service users monies and staff not accepting gifts or becoming involved in the making of or benefiting of service user wills. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 15 Although the above policies are compliant with requirements and recommendations, it is recommended that they be personalised to reflect the actual requirements and practices of Chaseside Care Home. This is particularly important in respect of the adult abuse policy that must clearly indicate the responsibility of the manager is to establish facts and it is the multi disciplinary strategy meeting that will determine who will investigate the allegation. In practice, the local protocol for the investigation of an alleged abuse was followed at Chaseside Care Home with the registered provider and registered manager demonstrating a clear commitment to ensuring the safety and protection of all service users accommodated. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24, 25 & 26 The standard of the environment within this home is good providing service users with a safe, comfortable and homely place to live. EVIDENCE: Service user bedroom accommodation remains comfortably furnished to suit the needs of the occupant and provided with a lock to the bedroom door and a locked facility for the safe storage of items of a private nature. All radiators in bedroom and communal accommodation are fitted with guards to prevent the risk of accidental injury and thermostatic devises have been fitted to all hot water outlets in service user accommodation to prevent the risk of accidental scalding. As stated in the previous inspection report, if a service user is informally assessed as not safe to hold a key to their individual bedroom accommodation, this should be formally risk assessed and documented. It is understood through discussion with the registered manager that risk assessment(s) have been completed in respect of this issue but they were not available to evidence Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 17 at the time of inspection. Please confirm in the Action Plan that risk assessments in respect of service users holding a key to their individual bedroom accommodation has been undertaken when appropriate, with the outcome incorporated in the individual care plan and regularly reviewed. All service users spoken with voiced satisfaction with their bedroom accommodation and stated they were happy and comfortable with their personal environment. The home is clean, pleasant and hygienic with a variety of policies and procedures to advise staff in the control of infection. Laundry facilities are sited in the basement area of the home and do not intrude on service users. The industrial washing machine has the capacity to meet disinfection standards and floor finishes are easily cleanable. However the laundry walls would benefit from attention to ensure these remain readily cleanable and it is recommended that an environmental risk assessment be undertaken in respect of staff having to climb steps to access the washing machine and dryer in order to minimise any risk associated with this task. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 & 30 There is a good mix of staff offering consistency of care within the home. The arrangements for the induction of staff and more advanced National Vocational Qualification (NVQ) training in care are good with the staff demonstrating a clear understanding of their roles. There is a structured process for the recruitment of staff that includes obtaining satisfactory references and clearances in order to protect service users. EVIDENCE: Chaseside Care Home staffing levels and skills mix are determined in accordance with the assessed needs of service users accommodated. Additional staff are on duty at peak times of activity and all night staff have ‘waking watch’ responsibility. There is sufficient ancillary staff employed to ensure standards in respect of domestic and catering are maintained. There is now a clear commitment to the training and development of all staff at Chaseside Care Home. All newly appointed staff undertake the ‘Skills for Care’ induction training programme and National Vocational Qualification (NVQ) training is positively encouraged. Currently one member of the care staff team has achieved an NVQ Level 2 certificate in care, two members of staff have received confirmation of successfully completing this award and a further four members of staff are waiting for verification. The home operates a structured recruitment process in order to protect service users. Since the last inspection, only one new member of staff had been Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 19 appointed. From observation of the staff member’s personnel file, it was evident that the policy and procedures in respect of staff recruitment had been followed. This included an application form, health questionnaire, formal interview, references and a Criminal Records Bureau, POVA First clearance had been obtained prior to the applicant actually taking up post at the home. However it is recommended that a system be devised to record the date the POVA First is received and a copy of the reference request indicating the name of the person and date be retained by the home. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 & 38 The home reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of, service users, staff and relatives. Systems are in place to ensure as far as possible the health and safety of service users, staff and visitors. EVIDENCE: Effective quality assurance and quality monitoring systems have been developed in respect of residents and staff and the home has achieved the ‘Investors In People’ award. Service user questionnaires have been developed and service user meetings introduced that supplement the informal daily dialogue that encourages discussion and information sharing. Since the last inspection, the views of family, friends and other stakeholders have now been sought on a formal basis through the introduction of a separate questionnaire that was evidenced at inspection. This system also helps to inform the internal quality audit to supplement the outcome of the service user surveys. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 21 A number of service users spoken with confirmed that they were asked for their views on a variety of topics with one service user stating that ‘things are much better’ at Chaseside since the new manager came and ‘we are asked what we would like’. Policies and procedures are available however the majority are generic in nature and should be reviewed and personalised to reflect the requirements and practices of the home. Service users financial interests are safeguarded by the financial procedures adopted by the home. All service users, wherever possible, are encouraged to remain financially independent or an independent advocate is approached to assists the service user with their financial affairs. When the home does retains monies or valuables in respect of a service user, this is appropriately recorded and secure facilities are provided for the safe keeping of monies and valuables held on behalf of the service user. In respect of monies and valuables, it is recommended that if a service user does not have the capacity to sign financial documents when receiving monies, a second member of staff should witness the transaction and counter sign the first staff member signature. The registered manager ensures the health, safety and welfare of service users through the development of a variety of policies and procedures and staff training initiatives. All staff undertakes a variety of health and safety training and further moving and handling and first aid training has been arranged to take place in the near future. It is recommended that a qualified first aider who has undertaken the more advanced ‘First Aid at Work’ course be on duty at all times and it is understood that all staff who have not done so, will receive training in respect of moving and handling, fire safety, first aid, food hygiene, and infection control in the near future Equipment in the home is regularly serviced. However it is recommended that risk assessments are carried out for all safe working practice topics including window restrictors to certain windows and that significant findings of the risk assessment are recorded. It is understood that water temperatures from hot water outlets in service user accommodation is tested on a regular weekly basis however this task is to be designated to a specific member of staff and outcomes routinely recorded. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x x 2 Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 23 YES 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 1 Regulation 4&5 Requirement Timescale for action 30/09/05 2. 7 15(1)(2)a b Reference must be made to Regulations 4 & 5, Schedule 1 of the Care Homes Regulations 2001 and Standard 1, National Minimum Standards-Care Homes For Older People. (Time scale of 30/06/05 not met) All sevice users must have a plan 30/09/05 of care identifying strengths and needs and how these will be addressed that is reviewed on a monthly basis. Revelent risk assessments must also be undertaken with significate outcomes incorporated in the care plan. 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 3 9 18 Good Practice Recommendations The pre admission assessment document could be further developed. It is recommended that the medication policy and procedures be kept in the medication cabinet. The Adult Abuse Policy should accurately reflect the local F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 24 Chaseside Residential Care Home 4. 5. 6. 7. 8. 24 26 29 35 38 protocal in respect of alledged abuse. Various other policies/procedures should be personalised to reflect the requirements and practices of the home. Please confirm that formal risk assessments have been undertaken if the service user is not provided with the key to their private accommodation. Laundry walls should be readily cleanable and an environmental risk assessment undertaken in respect of staff safety. Copies of reference requests should be maintained on the individual staff file and a system developed to record when the POVA First is received. It is recommended that when a service user does not have capacity to sign financial documents a second member of staff should witness the transaction and countersign. All staff who have not done so should receive appropriate health and safety training as indicated in Standard 38.2 and a qualified first aider should be on duty at all times. Formal risk assessments should be carried out for all safe working practices. Chaseside Residential Care Home F57 F09 S38212 Chaseside V245431 190805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit 1, Tustin Court Portway Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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