Inspection on 01/02/06 for Chasewood

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Chasewood 02/06/09

Chasewood 09/12/08

Chasewood 08/05/08

Chasewood 08/11/07

Chasewood 15/06/07

Chasewood 07/12/06

Chasewood 11/05/06

Chasewood 05/05/05

Chasewood 06/01/05

Chasewood 18/06/04

Similar services:

Maple Lodge

Heathlands

Breme

Ravenhurst

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Chasewood 39 School Lane Exhall Coventry West Midlands CV7 9GE Lead Inspector Patricia Flanaghan Unannounced Inspection 1st February 2006 12:00 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 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chasewood Address 39 School Lane Exhall Coventry West Midlands CV7 9GE 02476 738211 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) Chasewood Care Ltd Mrs Catherine Tranter Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered manager must work at least 3 days a week supernumerary to the care rota in order to complete management tasks. 5th May 2005 Date of last inspection Brief Description of the Service: Chasewood is a converted, detached property, set back from the road and providing accommodation on two floors. The home is registered to provide care for 22 elderly service users with dementia. Unit 1 is located on the ground floor and provides accommodation for fourteen service users. There is a large open-plan communal area at the centre of the ground floor, and leading off from this area are three wings providing bedrooms, a kitchen, laundry and the managers office. There is a further lounge with conservatory leading into the garden. There are ten single bedrooms for service users at ground floor level, and two doubles. There is a shaft lift to the first floor, as well as the stairs, where the second unit is located. This provides accommodation for eight service users, with a lounge, a dining room (with a kitchenette), and six bedrooms, two of which are doubles. There are two separate lavatories at this level, a bathroom and a shower room. French windows lead onto the rear garden, and the home has a small patio area to the rear of the property. To the front of the home there is parking space for about six cars. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the period 2005/06 and was conducted by two inspectors. The deputy manager was available throughout the duration of the inspection and the manager arrived once informed. During the inspection records were examined in relation to care provision for the residents, staff records and those concerning health & safety and management of equipment in the home. A tour of the building was carried out. Seven residents and three staff members were spoken with. A service questionnaire was completed by the home and returned to the Commission for Social Care Inspection (CSCI) prior to this inspection. The manager was asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Ten responses from residents and five responses from visitors/relatives had been received by the CSCI at the time of writing this report. The responses were mostly positive, however, five residents said they did not like living in the home, two relatives felt that there are not always sufficient numbers of staff on duty and three said they were not aware of the home’s complaints procedure.. Comments made from residents include “I have not been here long, but I like it,” “I like the staff, the food is very good,” and “It’s better than it used to be.” Comments from relatives include “…improvements to the lounge much nicer than previous, the new chairs are very nice and more hygienic” What the service does well: What has improved since the last inspection? Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 6 The manager now ensures that all prospective residents have a full assessment prior to admission to the home. New tables and chairs have been purchased for the dining room making the room a pleasant area for residents to dine in. Formal supervision of staff has commenced. 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. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 All residents have a full assessment prior to moving into the home ensuring that the home can meet their needs. Residents and their families are verbally informed after the assessment that the home can meet their needs prior to admission. EVIDENCE: Two profiles were examined and there was written evidence that an assessment had been conducted. This was not dated or signed by the person completing the assessment. The manager must ensure that this is done enabling evidence that the assessment was completed prior to and not after admission. Through discussion it was established that the home inform the resident and their relatives verbally that they are able to meet the assessed needs. This is not recorded in the residents profile nor followed by a letter. The two profiles also contained life information ‘Getting to know you’ completed by the family containing important life information including important dates and people. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 Not all of the care needs of the residents are set out in individual care plans relying on the staff knowing the residents this could result in care needs not being sufficiently met. Not all the health care needs of the residents are sufficiently met possibly resulting in deterioration of health. The residents are not completely protected by the procedures used in the management of medication. EVIDENCE: The care plans examined were confusing. In one profile the care plans had been written on Chasewood Lodge, the sister home, headed paper and it was difficult to determine what care was required. Three separate care plans were available for mobility, written over a year period, an it was not clear which care plan should be used: a) ‘D has slowed down and cannot walk without assistance.’ b) ‘ Now has complete lack of mobility – to use hoist when transferring.’ Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 10 c) ‘ Mobility can fluctuate daily. Can mobilise with frame other days use hoist.’ There is no information concerning the behaviours exhibited by the resident that would guide staff to deciding that the hoist should be used. Staff spoken to were aware of the needs of this resident, however, unclear care plans can result in poor care provision and potential harm to the resident and staff. There was no written evidence in this resident’s profile that the family had been involved or consulted concerning the resident’s care needs. There was also no written evidence of any reviews, despite this resident living at the home since 2002. The ongoing risk assessments in this profile were poor. The risk assessment for the potential development of skin damage had not been completed for a year and it was noted that the calculation was incorrect. Nutritional risk assessments were also poor. The resident’s weight was not consistently measured and the weights seen were very inconsistent (12/12/05 = 12st 11lbs; 27/06/05 = 9st 7lbs; 23/01/05 = 11st 3lbs). There was no evidence that the staff had recognised this inconsistency and checked the scales, methods used to weigh or taken action if the weights were found to be correct. This could put the resident at risk of malnutrition. The risk assessment for Manual Handling and mobility was carried out in January 2005; no further assessments have been conducted. Bed rails are used to prevent the resident from falling out of bed. The next of kin had signed a risk assessment in February 2004 this had not been resident-visited. The second profile seen had similar issues; care plans were insufficient to guide staff to the needs of the resident. One care plan stated that assistance was required with personal care, it did not guide staff to the level of assistance required nor did it highlight any areas of concern. The profile was confusing with different sets of care plans in various places throughout the folder. This could result in the wrong care being given to the resident. Two statements were found with no corresponding care plans a) ‘falls related to fits’ and b) ‘risk of eating soap’. As there are no care plans giving guidance on the actions to be taken, this could result in staff omitting the care required to ensure the safety of this resident. There was also no evidence that adequate nutritional assessments had taken place. The weighing of this resident was also inadequate. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 11 There were no psychological assessments available in either profile. Medication storage, administration and management were assessed. Medication is stored in a locked sideboard. It is suggested that a suitable medication trolley is acquired so that the staff can take the medication to the residents at the appropriate time. The storage was poor, residents’ medication in boxes was mixed together and some medication had fallen from the original packaging. It was found that a resident prescribed warfrin had been given the wrong dosage over a number of days, and staff are failing to check the new prescription and ensuring that the correct amount is given. One resident prescribed antibiotics had not been given the amount that the staff had signed for. The Medication Administration Records (MARs) were not completed for every event of medication administration. An immediate requirement notice was issued at the time of the inspection related to: 1. Incorrect administration of Warfrin to a resident 2. Poor practices in relation to administration of medication, maintaining appropriate records of administration and storage of individual medication. 3. Poor management of the drug fridge used to store medication. The fridge was full of supplement drinks with no names; it was dirt, required defrosting and had no thermometer. The fridge felt too warm and was housed in a small room that was very hot. The registered manager faxed the Commission three days after the inspection informing that these issues had been dealt with. This will be assessed again at the next inspection. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 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 the following standard(s): 12 and 14 Mostly the lifestyle experience in the home matches the expectations of the residents. Residents are assisted in most cases to make choices. EVIDENCE: There were some activities occurring during the day. One resident was seen completing ‘word searches’. His profiles indicated that this is what he enjoys doing and the staff were seen interacting with him and offering help. Another resident’s psychological needs were met using doll therapy and staff interacted well with this resident reducing anxiety. Other residents were seen listening to music and interacting with each other and staff. Two residents spoken to on the first floor stated that at times they were bored and would like more to do at times. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 13 As detailed in the previous inspection report of 05/05/05, the service does not have an activity plan in place, all activities are ad-hoc and carried out depending on who is on duty and their own likes and dislikes. There is no formal record to indicate that residents participate in activities. Through observation and discussion it was determined that in most cases staff assist the residents to make choices concerning their daily lives, such as what they want to eat, when they go to bed and what they wear. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were inspected at this visit. Standards 16 and 19 were reviewed at the inspection of 05/05/05 and assessed as met. EVIDENCE: Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24 and 26 The environment is poorly maintained which impacts on the experience of those living at the home. EVIDENCE: The bedrooms throughout the home were visited. The following was found: ♦ ♦ ♦ Broken furniture, such as wardrobe door handles broken or missing, veneer on furniture doors was lifting, chairs seats torn. One bedroom smelled very strongly of bleach and had an underlying smell of stale urine. All bedroom doors on the ground floor were locked. One resident tried to enter their room and called for the door to be opened stating “ Why is this door always locked?” Staff did not answer his question but did open the bedroom door. In one bedroom the chest of draws was damaged and this was also seen at the last inspection. DS0000004216.V282109.R01.S.doc Version 5.1 Page 16 ♦ Chasewood ♦ ♦ In one bedroom there was an unpleasant smell, the bedside table had urine stains on the shelf and there was a very strong smell from this area. All bedroom floors on the ground floor and some on the first floor had lino, the majority of these floors were sticky to walk on. Positively, most of the rooms were personalised and the residents are encouraged to bring in personal items. On the ground floor there is an open plan lounge and dining area. New tables and chairs have been purchased for the dining room. Throughout the home there were pockets of unpleasant smells in both bedrooms and communal areas. On arrival the reception area had a stale cooking smell and this area is also in need of re-decoration and cleaning. The chairs in the lounge have been laid out to encourage interaction between the residents. The kitchen leads directly into the dining area. At the beginning of the inspection this door was open, as the cook was in the kitchen with the back door open letting a very cold draught into the residents area, which was uncomfortable. An examination of the laundry area found it to remain untidy and disorganised with items not required for the laundry being stored in this area. This concern was raised at the last inspection visit. A discussion was held with the manager regarding clearance of the clutter from the room. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The induction and foundation training remains poor and this might reduce the care staffs’ competence and could result in the risk of harm to the residents. EVIDENCE: The induction programme still requires updating to meet the requirements for new staff. The records of staff that attend training are recorded individually and it was difficult to see who had attended training, dates attended and when refresher training was needed etc. The manager was advised to put together details of the training records, which will enable her to keep training up to date for all staff. A discussion was held on how a training matrix document could be produced. These records will be examined again at the next inspection. The manager also said that 5 members of staff had achieved an award in NVQ Level 2 or Level 3 in care with 5 staff members working towards this award. On the day of the inspection visit a number of care staff were seen to be enrolling on ASET courses in Dementia Care and Safe Handling of Medication. This is seen as good practice. During the inspection visit staff were seen to demonstrate a good understanding of the needs of the residents and were observed dealing appropriately with challenging behaviour. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The manager is demonstrating good leadership skills, whilst acknowledging the areas in which the home needs to improve. The quality monitoring systems in the home are insufficient and there was no evidence that the home is run in the best interest of the residents. Residents’ financial interests are not protected by the home’s policies and procedures. Staff are appropriately supervised. Health and safety was generally well maintained, some issues needed to be addressed to ensure the residents live in a safe environment. EVIDENCE: A registered manager has recently been appointed to the home. She has worked for the company for some years, latterly in a senior role. The manager has recently achieved the Registered Managers’ Award and NVQ4 in care. In addition to the mandatory health and safety training, the registered manager has undertaken periodic training to update her skills. Staff spoken to during the inspection were pleased with this appointment. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 19 The manager acknowledges that there remains a significant number of statutory requirements to be met to achieve effective and efficient management of the home and provide consistent quality of care and quality assurance. The manager advised that the home does not have a suitable quality assurance or monitoring system in place, and there was no evidence to show that the residents or their families are consulted about the service they receive and their experience of living in the home. The manager was given advice on how to implement a quality assurance system within the home. The Registered Person has not provided the Commission with a monthly report on the conduct of the home as required by Regulation 26. The personal allowance monies held at the home on behalf of residents were not handled in line with the homes policy of handling resident’s money. The home takes charge of some of the personal allowances of a number of residents. All monies are stored individually and records retained. Some discrepancies were noted during the inspection. It was later explained that monies had been withdrawn to pay for chiropody, but records had not been amended. Monies and records must be checked on a daily basis. The manager must audit the monies held for all residents in the home to ensure records are up to date and in order. These records will be examined again at the next inspection. All staff are now provided with formal supervision on a regular basis and training is discussed as part of the process. The manager and deputy were advised to ensure that all elements of Standard 36 are included in the supervision process. Various records were seen to evidence that the health and safety of residents and staff is maintained. Servicing records for the lift and hoists, boiler, fire equipment were some of the records seen. An audit sheet for general maintenance is completed by the home’s maintenance man. It could not be evidenced that all statutory training for staff is up to date, for example, moving and handling training appeared to be required for a number of staff. Staff training in the mandatory areas of fire safety, first aid, moving and handling, food hygiene and infection control must be documented on a training plan, which gives details of staff who have up to date training, training arranged and dates when refresher training is needed. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 2 X 2 X 2 2 STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 21 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 OP4 Regulation 12 14 Requirement The registered provider and manager must ensure that the resident and/or their family receive information confirming that the assessed needs can be met by the home. (Outstanding from July O5) 2 OP7 15 S3 A system for involving the residents and/or their families in determining their care must be implemented and records maintained. Evidence of involvement must be available for inspection. (Outstanding from July O5) 3 OP7 15 13 S3 The residents care plans must be evaluated monthly. The information in the care plans must meet with current good practice (Outstanding from July O5) 31/03/06 30/04/06 Timescale for action 30/04/06 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 22 4 OP8 14 17 The registered provider and manager must ensure that all residents are weighed a minimum of monthly and more frequently where there is evidence of weight loss. A full nutrition assessment must also be completed monthly (Outstanding from January 05) 31/03/06 5 OP8 S3 12 13 The registered provider and manager must ensure that risk assessments related to pressure sore development are produced and appropriate pro-active care plans are produced. (Outstanding from July O5) 31/03/06 6 OP9 13 The registered manager must ensure that the correct dose is recorded on the Medication Administration Records and checked by two staff. The registered provider must ensure that medication for administration is stored in a trolley that can be taken the resident areas. Present storage on the ground floor is unacceptable. The registered manager must ensure that all medication prescribed is given and that records maintained reflect this. Falsifying documentation is an offence. 01/02/06 7 OP9 13 30/04/06 8 OP9 13 01/02/06 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 23 9 OP9 13 The registered manager must ensure that the drug fridge is kept clean and the amount of supplements stored is monitored. The fridge temperature must be checked daily and recorded to ensure that it is maintained at an acceptable level. Immediate Requirement issued. Information received that fridge now clean. Home must continue to maintain this 01/02/06 10 OP12 14 The registered provider and manager must ensure that activities are organised and records are maintained. (Outstanding from July O5) 31/03/06 11 OP19 23, 16 The registered provider and manager must ensure that there is a programme of routine maintenance and renewal available for inspection. The registered provider must also ensure that all outside areas are maintained. (Outstanding from July O5) 30/04/06 12 OP20 23, 16 The registered provider and manager must ensure that all communal areas are decorated to a suitable standard and that furniture and fittings are in good repair. (Outstanding from July O5) 30/04/06 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 24 13 OP24 23, 16 The registered provider and manager must ensure that all furnishings in the residents own rooms are in good repair and suitable for use. The registered provider must supply a locked facility for the individual use of each resident. (Outstanding from July O5) 30/04/06 14 OP26 12 16 The registered provider must ensure that the home is kept clean and free from offensive odours. (Outstanding from July O5) 31/03/06 15 OP26 23(2)(d) The registered provider must ensure that the laundry area is kept clean and tidy and is suitably organised (Outstanding from July O5) 31/03/06 16 OP30 12 18 17 OP33 26 The registered provider and manager must ensure that all new employees complete the induction programme in six weeks and that the records are up to date. Foundation training must be developed to follow on from the induction training. The Registered Provider, or his representative, must visit the home at least once a monthly and prepare a written report on the conduct of the care home. A copy of this report must be forwarded to the Commission for Social Care Inspection (CSCI). 31/08/05 31/03/06 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 25 18 OP33 24 19 20 OP35 OP38 17(2) 18(1)(c) The registered provider must 30/04/06 ensure that there is a suitable and recognisable quality assurance and quality monitoring system demonstrating that the service is assessed and action is taken to update where required. Correct and up to date records 31/03/06 must be kept of monies looked after on behalf of residents. The registered manager must 30/04/06 forward to the Commission a copy of the staff training and development programme for the home. This must include details of training in the mandatory areas of first aid, fire safety, food hygiene, moving and handling and infection control. Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 26 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 OP3 Good Practice Recommendations It is recommended that all documentation related to residents and staff is signed and dated when completed to assist with auditing and demonstrating when documentation is completed. The manager should ensure that formal supervision of staff incorporates all the elements of Standard 36. 2 OP36 Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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. Extracts may not be used or reproduced without the express permission of CSCI Chasewood DS0000004216.V282109.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!