Inspection on 05/05/05 for Chasewood

This inspection was carried out on 5th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 01/02/06

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 Coventry West Midlands CV7 9GE Lead Inspector Suzette Farrelly Unannounced 5 May 2005 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. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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 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 PC - Care Home only 22 Category(ies) of DE(E) Dementia over 65 - 22 registration, with number of places Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 6 January 2005 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 manager’s 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 E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day starting at 09:30 am and finishing at 08:30 pm, this enabled the inspector to obtain an overall view of the complete day for the residents. The acting manager, Ms Catherine Tranter was present throughout the inspection. This was the first of two inspections to take place this year. A tour of the home was completed and all records and paper work were looked at in the main lounge area giving the inspector an overall view of the attitude and behaviour of staff toward the residents. Records related to the employment of staff were examined. Two members of care staff were interviewed; the acting manager and all residents were seen. The inspector spent some time with three residents looking at their own rooms and discussing their experience of care. No relatives or others involved in the home were seen. Throughout the inspection the care staff spent most of their time with the residents and there was a friendly atmosphere. One resident stated that the staff looked after her very well and said ‘I don’t know what I would do without them, they’re brilliant.’ Members of staff were able to discuss common conditions in older people and the skills needed to care for those with dementia. The paper work was disorganised and the home required decorating. What the service does well: The care staff have a good ability to build and maintain useful, productive and caring relationships with the residents in their care. Laughter and fun were seen and the residents spoken to reported that they felt cared for and the staff joined in activities with them. There is very good general training available for the care staff to assist them in their continued education and to give them the opportunity to learn more skills. The overall care of the residents is good, they were well dressed, and the staff responded to their needs throughout the day. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Following are the areas where this service could do better. All areas have been discussed with the acting manager. • • The service must ensure that they have a suitable Statement of Purpose describing how the service meets the care of residents and any specialist treatments offered. The service must also ensure that there is a Guide for residents and their families prior to admission to enable choice in the service that is chosen. The Guide must contain information about the services offered and other costs of living at the home; this must also contain the most recent inspection report. The home must ensure that a full assessment of residents’ needs is carried out before admission to make sure that the home can meet these needs. The management of the home must ensure that the resident and their family are aware that the home can effectively meet any assessed needs appropriately. The management of the home need to ensure that all records maintained relating to meeting the needs of the residents and other records concerning the maintenance of the home must be better organised and easy to find. The management must ensure that care needs of residents are clearly written down in the residents’ individual records and where it is possible the resident and /or the relatives are involved in this process. The management must ensure that ongoing assessments concerning nutrition and skin care are carried out and where a risk is recognised care to prevent further problems is written down and carried out. The service is advised to keep clear records of other professionals such as the chiropodist, dentist, optician and others that visit the resident. These records should contain information about who visited and the outcome of the visit. The management should ensure that there is information about individual residents’ interests, hobbies, social and cultural needs and ensure that these are recorded. The home should be able to show how these areas of the residents’ life are met. The management must produce a plan of routine work around the home, showing replacement of equipment, re-decoration and repair or replacement of fixtures and fittings in all residents’ areas. The management must ensure that the cleanliness of the home is improved and that unpleasant smells are dealt with promptly. E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 7 • • • • • • • • Chasewood • • • • The management of the home must also assess the use of bathing facilities in the home and consider how assisted bathing facilities can be increased. The organisation and tidiness of the laundry needs attention. The management must also make sure that all new employees are given the correct training when they begin working at the home. All care staff must also have supervision six times a year to ensure that care, issues concerning work procedures and the care workers abilities are dealt with on a regular basis. The management must ensure that the residents, their families and others involved in the home are consulted about the service and its’ facilities. The management must also audit other areas of the home and show where change has happened to improve the service. 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 E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5 The home does not have a suitable Statement of Purpose or Service User Guide resulting in insufficient information available to the resident that would help them to make a choice about where they live, infringing their Human Rights. The residents’ needs before admission are not suitably assessed and therefore cannot be assured that these would be met. The residents and their families do not know that their care needs will be met and therefore cannot participate in the process reducing their choice and human rights. All residents and their families are invited to visit the home prior to admission giving them the opportunity to assess quality, facilities and suitability of the service offered. EVIDENCE: Through discussion with the acting manager it was noted that the Statement of Purpose and the Home’s Guide for residents is not complete and these Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 10 documents are not available to the residents and their families. The staff spoken to did not understand the value of these documents and the acting manager said that the company puts these together. Assessments carried out before admission did not cover all the areas suggested by the standards. It was seen in some of the files that the information was incomplete and the type of care planned and given did not always meet the needs. In one resident’s notes the information was difficult to find as they were poorly organised, the care plan did not reflect the initial assessment and there was no information to indicate further assessments and the staff had not recorded why this was. As the assessment of needs is poor, the residents and their families cannot be assured that all their care needs will be met. Residents spoken to were unaware of this. This has resulted in them not being given the opportunity to take part in the initial planning their own care. Residents and their families are invited to visit the home prior to admission to ensure that it meets their needs. This gives the residents the opportunity to decide if the service is suitable for them. Some residents spoken to stated that their families had visited the home and that they had trusted them to make a good decision. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10, The resident’s health, personal and social care needs are not suitably recorded and information is missing which could result in the risk of harm to the resident. The resident’s health care needs are not completely met which could increase the risk of harm to the resident. The resident’s right to privacy is respected increasing their sense of well-being and self worth. EVIDENCE: Three residents care records were examined and they were disorganised where information could not easily be found. This could result in new staff not referring to the information available and poor care practices occurring with the possible increase of harm to the residents. The care plans available did not deal with present concerns and care needs of these three residents. One resident had a severe fungal infection of his fingernails, there was no care plan and after discussion with care staff it was apparent that this condition was not being treated. Another resident did not Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 12 have a care plan to monitor her mental health and again after discussion it was apparent that the staff had minimal understanding of her mental health needs. The care plans were not evaluated and it could not be confirmed that the care prescribed was required, which could increase the risk of harm to the resident. The residents’ health needs are not being met. The service does not review nutritional needs monthly and fail to weigh the residents on a regular basis even when there is evidence of weight loss. Three care profiles examined showed that one resident had not been weighed since July 2003. This lack of concern for nutrition could result in serious harm to the residents due to malnutrition and dehydration. The assessment used to assess the risk of pressure sore development is poorly used. One resident’s profile stated that he had minimal risk, however, he has very poor mobility and was seen sitting for more than three hours on a hard chair. A member of staff stated that he was very reluctant to stand and they could not move him. He was not seated on a pressure-relieving cushion. This resident is at risk of developing pressure damage. There are records to indicate visits from other professionals such as the chiropodist, dentist, or district nursing services. In one resident’s records it indicated that the doctor had not seen the resident since March 2004. The acting manager stated that the doctor was reluctant to visit for routine check ups and when residents were reported as unwell. Residents spoken to said that they are cared for and that they felt that the staff respects their privacy. Residents were all dressed appropriately in their own clothes. They have access to a communal phone and all residents can use the office phone for private calls if they wish. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 13 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, 13, 15 The social, cultural, religious and recreational interests are not completely met by the service and therefore the residents’ life experience of the home could possibly not met their expectation. This could result in poor self-esteem and psychological harm to the residents. The service ensures that visitors are made welcome and the residents’ benefit from visits from family and friends. The residents have suitable meals four times a day, the surroundings are drab and not inspiring, this could result in reduced eating and associated health concerns. EVIDENCE: 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 record to indicate that residents participate in activities. One resident was seen listening to music through headphones. These are her own purchased by her family. During the afternoon and early evening the staff remained in the lounge/dining area and talked to the residents. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 14 Four residents were seen sleeping, two residents had fallen asleep at the dining tables, staff made not attempt to wake them or encourage them to sit in a more comfortable place. During the inspection no visitors were seen. One resident stated that her daughter visits every weekend and stays for a number of hours, or she goes to her daughter’s house. The service has a signing in book for all visitors in the reception area, this is not consistently completed and it could not be established how frequently residents receive visits. The acting manager stated that visitors are always made welcome and there are no restrictions on visiting the home. The resident’s have four meals a day, lunch, tea and supper were seen. The food was well presented and most of the residents sat at the tables to eat. Residents who required assistance were given help in a quite and professional manner. Menus were not seen and there was no information in the communal areas related to meals to inform the residents and their relatives of the menus for that day. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 15 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 All complaints received by the home are dealt with promptly and in accordance with local and national guidance, therefore protecting the residents’ rights. Policies and procedures concerning the protection of vulnerable people are appropriate and residents are protected from harm. EVIDENCE: The home has not had any recent complaints; the policies and procedures are suitable. Discussion with the acting manager and three care staff indicated that they would deal appropriately with complaints in accordance with local and national guidelines. The Commission has received no complaints since the last inspection. The home has suitable policies and procedures for the protection of vulnerable adults and there is a suitable Whistle Blowing Policy. The acting manager stated that staff have received training in the recognition and management of abuse, the training records were seen and these are incomplete. Discussion with the acting manager and three staff showed that they have a good understanding of issues related to the protection of vulnerable adults. Staff also discussed how they would deal with verbal and physical aggression. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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) 19, 20, 21, 22, 23, 25, 26 The general and private areas of the home required some repairs and redecoration and more cleaning in places, areas were untidy and lacking a homely feel reducing the quality of life for the residents. There are insufficient bathing facilities, which may reduce the quality of the residents’ life. The home has suitable equipment to assist with mobility and access to all areas of the home ensuring that residents are able to maintain their independence where possible. EVIDENCE: The main communal area consists of a lounge area with integral dining area. The dining area has two main tables with not enough chairs to seat all the residents together. This area does not feel homely and the small dresser was untidy. The lounge area has a selection of chairs that are suitable and meet the needs of the residents. This area was also disorganised and lacks a homely feel. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 17 The garden is also untidy and it was noted that the grass needed cutting. Residents spoken to said they did not use the garden very often. There is a lift to the first floor and the home had lifting equipment, which meets the needs of the residents and assist them to maintain their mobility where possible. One resident was seen with a walking frame and staff encouraged her to use this to walk around the home. There are not enough assisted bathing facilities for the residents, during the tour of the home one assisted bath and a shower were seen. Other bathing facilities available are not assisted and it was confirmed that these are not used, as the residents cannot get in and out of them. It was noted that a number of bedrooms, the shower room, bathroom and dining area have vinyl flooring; these can become very slippery when wet and the management have not completed a risk assessment to address this issue. A number of residents’ bedrooms were seen and it was noted that some of the furniture is in poor condition and needs to be repaired or replaced. The bedrooms also require redecoration and one bedroom seen lacked a homely feel and felt cold and uninviting. One resident showed the inspector her room and was very pleased with the size and lay out, she also showed her photographs of her family. It was noted that the general cleanliness of the home is poor and various areas such as cupboards, draws and surfaces required more thorough cleaning. There were areas that had unpleasant smells; this was noticed in some bedrooms. The acting manager was aware of this and discussed issues related to continence management. The laundry was untidy and poorly organised. A number of items not required for the laundry were stored in this area. The windowsill and shelving were used as storage and these areas were dirty. Clothes seen in the laundry had been properly washed and ironed and were waiting to be taken to the residents rooms. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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 are sufficient numbers and skill mix of staff on duty at all times ensuring that the assessed care needs of the residents is met. Approximately one third of staff employed are qualified to National Vocational Qualification level 2 or 3 in care ensuring that the residents are in safe hands. The employment of staff is carried out in accordance with the homes’ policies and procedures ensuring that residents are supported and protected. The induction and foundation training is poor and this might reduce the care staffs’ competence and could result in the risk of harm to the rsidents. EVIDENCE: During the inspection it was noted that there were sufficient staff on duty to meet the needs and demands of the residents. Staff rosters were also seen and these demonstrated that the home covers any sickness or absence with their own staff. Two staff spoken to had a very positive attitude to attending work and through discussion showed their understanding of the residents assessed needs. Records seen showed that five staff have a NVQ 3 in Care and one has a NVQ 2. A further five staff have started their NVQ training. This increases the understanding and skill of caring amongst the staff. From observation and discussion with staff and four residents it was confirmed that the staff are aware of the residents needs and are able to meet these. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 19 Employment records of four new employees were examined and it was found that all new employees are checked to ensure that they do not have a criminal record that would affect their ability to protect the residents. Staff are also checked for inclusion on the Protection of Vulnerable Adults list. All these checks, including references ensure that the residents are protected and safe from abuse. The induction programme needs up dating to meet the requirements for new staff, one induction programme was seen and this had not been completed. Other training offered by the home for staff cover various areas such as Dementia Care Training, Challenging Behaviour, Continence and Pressure Sore and training related Record Keeping. The records of staff that attend training are not up to date and it was difficult to see who had attended. Two staff interviewed demonstrated a good understanding of the needs of the residents and had a good working knowledge of how to deal with verbal and physical aggression and complaints. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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) 31, 33, 36 There is no permanent manager at the home and this may result in poor leadership and a lack of direction of staff resulting is risk of harm to the residents. 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 resulting a lack of choice for residents and possible risk of harm. There is no supervision for staff, which may result in risk of harm to residents. EVIDENCE: An acting manager who has been in post for eight weeks at the time of the inspection manages the home. The company are giving her three months trial, after which a decision will be made concerning a permanent position. The acting manager has worked for the company for the past nine years and worked as a deputy manager in another service. She is suitably qualified for the role and through discussion demonstrated that she is aware of the issues Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 21 and concerns about the service. Staff spoken to were pleased to have a manager and stated that they were able to share concerns and were supported. 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 acting manager audits accidents, incidents and other events monthly, information from these are not public. There is no formal supervision of staff in the home this is a useful tool to ensure that working practices are in line with the homes’ philosophy and ethos. The staff spoken to were unaware of the requirement to receive supervision six times a year. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 2 2 3 2 x 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x x 1 x x Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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 OP1 Regulation 4,5 Schedule 1 Requirement The statement of Purpose and Service user Guide must be reviewed and a copy of these documents must be forwarded to the Commission when completed. (This remains outstanding from the last inspection) The registered provider and manager must ensure that a full and comprehensive assessment is carried out prior to admission to the home. The assessment must cover all areas of Daily Living as demonstrated in 3:3 of the National Minimum Standards. for older people. 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. A system for involving the residents and/or their families in determining their care must be implemented and rekords maintained. Evidence of envolvement must be available for inspection. The residents care plans must be Timescale for action 31/07/05 2. OP 3 14, Schedule 3(1)(a) 31/07/05 3. OP4 12(1), 14(1)(d) 31/07/05 4. OP7 15(1)(2)( a)(c)(d), Schedule 3(1)(b) 31/07/05 5. OP7 15, 13 31/08/05 Page 24 Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 4(b)(c), Schedule 3(1)(b) 6. OP8 14(1)(a)( 2), 17(1)(a), Schedule 3(3)(m), Schedule 4(13) Schedule 3(3)(n), 12(1), 13(1) 14(1)(a), 15(1), 4(1)(c), 16(2)(m)( n), Schedule 1(9) 23(2)(d)( 5), 16(2)(j) 7. OP8 8. OP12 evaluated monthly. The information in the care plans must meet with current good practice The registered provider and manager must ensure that all residents are weighed a minimum of monthly and more frequemtly where there is evidence of weight loss. A full nutrition assessment must also be completed monthly (This outstanding since January 2005) 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. The registered provider and manager must ensure that activities are organised and recorded are maintained. 31/07/05 31/07/05 30/09/05 9. OP19 10. OP20 23(2)(d)( 5), 16(2)(j) 11. OP21 23(2)(j) The registered provider and 30/09/05 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. The registered provider and 30/09/05 manager must ensure that all communal areas are decorated to a suitable standard and that furniture and fittings are in good repair. An action plan to address this is to be sent to the Commission within 28 Days There are insufficient assisted 31/08/05 bathing facilities for the residents. The registered provider must produce an action plan with time scales stating how this is to be addressed, this must Version 1.30 Page 25 Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc 12. OP24 13. OP25 23(2)(d)( 5), 16(2)(j), 14(1)(a), 12(4)(a), 13(4)(a)(c), 23(2)(m) 23(1)(a)( 2)(p)(5) 14. OP26 15. 16. OP26 OP30 12(1)(a), 16(1)(2)(j )(k), 13(3)(4)( a)-(c), 23(1)(a(d ) 23(2)(d) be forwarded to the Commission within 28 days. 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. The registered provider must ensure that the following is addressed a) re-painting of windowsills and windowframes b) assess and repair broken radiator guards. The registered provider must ensure that the home is kept clean and free from offensive odours. 30/09/05 30/09/05 31/08/05 17. OP31 18. OP33 19. OP36 The registered provider must ensure that the laundry area is kept clean and tidy. 12(1)(a)( The registered provider and b), manager must ensure that all 18(1)(a)(c new employees complete the ), induction programme in six 13(4)(c) weeks and that the records are up to date. Foundation training must be developed to follow on from the induction training. 8(1)(a) The registered provider must ensure that the acting manager applies for registration with the Commission as soon as possible. 24(1)(a)( The registered provider must b)(2)(3) 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. 18(1)(2), The registered provider and 19(1)(a)(c manager must ensure that all ) care staff receive supervision six E53 s4216 Chasewood v225174 050505 stage 4.doc 31/08/05 31/08/05 31/08/09 31/08/05 31/08/05 Chasewood Version 1.30 Page 26 times a year and records are maintained to demonstrate this is occurring. 20. 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 OP19 Good Practice Recommendations It is recommended that the management produce a policy and procedure from the Department of health Guidance on the Protection of Vulnerable Adults to ensure that staff are fully aware of their responsibility under this act. Chasewood E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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 E53 s4216 Chasewood v225174 050505 stage 4.doc Version 1.30 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. 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