Inspection on 08/05/08 for Chasewood

This inspection was carried out on 8th May 2008.

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 08/11/07

Chasewood 15/06/07

Chasewood 07/12/06

Chasewood 11/05/06

Chasewood 01/02/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Chasewood 39 School Lane Exhall Coventry West Midlands CV7 9GE Lead Inspector Ashley Fawthrop Key Unannounced Inspection 8th May 2008 10:00 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.V363940.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 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.V363940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered manager must work at least 3 days a week supernumary to the care rota in order to complete management tasks. 8th November 2007 Date of last inspection Brief Description of the Service: Chasewood is a converted, detached property, providing accommodation on two floors. The home is set back from the road and to the front of the home there is parking space for about six cars. The home is registered to provide care for 22 elderly people with a dementia. The ground floor of the home provides accommodation for fourteen people. 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 a conservatory leading into the garden. Ten single bedrooms are provided for people at ground floor level, and two shared rooms. There is a shaft lift to the first floor, as well as the stairs, where accommodation is provided for eight people. Facilities provided on this floor are a lounge, dining room (with a kitchenette), and six bedrooms, two of which are shared rooms. There are two separate lavatories at this level, a bathroom and a shower room. On the ground floor French windows lead onto the rear garden, and the home has a small patio area to the rear of the property. Information about the home is available in an information booklet provided in the entrance of the home. The manager has advised on 8th November 2007 that the current fees for a place in the home is £408 per week. Other additional charges include the hairdresser, chiropody, personal toiletries, newspapers and magazines. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a no star; this means that people using the service receive poor outcomes. This inspection was unannounced and the visit to the home lasted one day. We would like to thank everyone who took the time to talk to me and express their views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents, adult protection issues, reports from other agencies, i.e., the Environmental Health Officer, and correspondence following the last inspection. This information was used to plan this inspection visit. Information about the service was also received in the form of an annual quality audit assessment. This gives us information about the home and it’s development and was completed by people who own the home and the manager. We case tracked three people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, we assessed all twenty-one key standards from the Care Homes for Older People National Minimum Standards, plus other standards relevant to the visit. We spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these people was looked at. Where possible, contact was also made with external professionals to obtain their opinions about the quality of services provided at the home. What the service does well: People are provided with information about the home before they move in this gives them the opportunity to assess whether the home can meet their needs or not. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 6 Senior staff and or social workers do assessments before people move into the home. This gives the staff up to date information about the needs of people so they can provide the most appropriate care. The environment is homely and comfortable there are sufficient bathrooms and toilets and the home meets the needs of people. Rooms are personalised giving a feel of individuality and ownership. People are protected by the complaints procedure, adult protection procedures and recruitment and selection procedures. Staff are trained to and have the skills to provide appropriate levels of care. What has improved since the last inspection? What they could do better: People should have their moving and handling needs assessed so that staff can move them safely with out the risk of injury to themselves or the person they are assisting. Where there are instruction to reduce a persons risk there should be a written record that the instructions have been followed, so that people know that the risk is being correctly managed. When new prescriptions come into the home these must be recorded on the administration sheet so that accurate records can be kept and reduce the risk of mistakes. Where people’s monies are held for safe keeping the recording system should be kept up to date and accurate so that people are seen to be protected from financial abuse. Records relating to tests to the fire system must be kept at the home at all times. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 6 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information continues to be available to people about the home and the home recognises that initial information is important to people. They are updating their statement of purpose. People wishing to use the service are assessed before moving into the home, so that the staff are sure that they can meet the needs of the individual. The home does not offer intermediate care. EVIDENCE: There have been no changes to the information made available to people about the home and the services it offers before they move in. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 10 The home continues to display an Information book’ in the entrance hall of the home, this gives people who are wanting to move into the home inform them of the services that the home offers. This information describes the services the home offers and is complemented with pictures of the home and some staff. The home is looking to update the statement of purpose with more information about daily activities. This would give people information about how they could continue with family and friendships and what opportunities they would have to continue with existing pass times. On case tracking the care plan of one person admitted into the home there was information available to the staff that had been gathered before the person moved in. Information included the reason for the admission and how the move would affect them emotionally. There was also a short history of their physical and emotional needs. This gave staff information to commence the care plan. The person said that they were happy to come and live at the home and that they understood they needed the extra support. Staff said that they support people when they first move in because even though they have made the decision to move it can still be upsetting. Other health care professionals had also been contacted the assessments showed that the home had looked at the specific needs of the people and had undertaken an assessment in the key risk areas. As the home is specifically offering care to people with a diagnosis of dementia, the home also undertakes some assessment of the specific needs related to their diagnosis. The assessments continue to show improvement in the content of these gave staff good information to help them start the care plan. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plans continue to improve and the home is serious about updating information. They are assessing risk and on the whole acting on the results. Mistakes and omissions are still being made that doe not guarantee that people are consistently safe. The medication system is monitored and improvements have been made to reduce mistakes, however, people are not yet fully protected. EVIDENCE: The care plans for three people were case tracked as part of the inspection. One related to a person relatively new to the home was well written and contained good information, but there was evidence that that the moving and handling assessment had not been completed. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 12 This means that the risk to both the person being assisted and staff helping had not been assessed increasing the risk of injury to both. Overall the recording in care plans had improved since the last inspection on the whole risk assessments were in place and there was evidence that reviews had been completed. The person managing the home said that they had audited all the care plans since the last inspection and had been working to bring them up to date and make sure all the relevant information was available. There was evidence that this was ongoing each care plan had been looked at and a list of outstanding information recorded when this was brought up to date the audit was signed and dated. This allows staff to give the most appropriate care as they have the most up to date information to work with. Staff said that they are involved in care plans on a daily basis and are in contact with families to update information. However, there continues to be instructions in risk assessments that are not being followed up. In one care plan it says that one person must be observed every 20 minutes but there is no written evidence that this is being done. Other information showed that antibiotics had been prescribed by the GP on the 6 May they were not collected from the chemist until the 8 May. This is an unacceptable period of time and should have been collected at the soonest possible time to prevent the person’s condition deteriorating. On reading the daily records there is evidence that staff are sensitive to people and respond well There was a record how one person was particularly upset and staff had reassured this person and had monitored how they were feeling and passed relevant information to other staff coming on shift. This shows that staff consider peoples feelings and pass information on so that they can approach the care consistently. The people running the home and staff should now increase information about social activities and what people want do this would give a more holistic picture about the person and would more accurately reflect their quality of life within the home. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 13 Evidence was available to show that people are given access to their GP and other health care professionals On inspecting the medication administration system showed that there had been improvements in the instances where mistakes had been made. The person running then home said that the medication system had been audited to show where common mistakes were being made. Staff had also been observed administering medications to make sure they are doing this correctly. Staff also undertakes training in the safe administration of medication. There was evidence in the form of photocopied prescriptions that had been prescribed for the month were available and staff use. This information makes sure that they are administering the correct medication. On inspecting the administration of medication the instances where staff had not recorded administration had reduced with only a few gaps, however, if regular audits are done then these can be reduced further. There was one significant mistake in the medication administration system that meant that the amount of tablets given could not be calculated against the number of tablets available because when one prescription had finished the next bottle of tablets had been started without booking them in. This is not safe practice and must stop immediately. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Activities are available, but need to be developed to reflect the individual needs and daily living skills of the people who live at the home. The standard of food is good but people living at the home could be more involved in planning the menu. EVIDENCE: On the day of the inspection there were no specific organised activities taking place, but staff were noted particularly in the afternoon to spend some individual time people playing music sitting and talking. Staff continue to organise activities but feel that this is difficult to do because of time constraints due to the amount personal care people need. Information in the AQAA said that he home was looking to employ an activity coordinator this had no happened at the time of the visit. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 15 The home had planned to organise more activities and outing but there was no evidence of this at the time of the visit. The recording of personal histories and what people like to do were inconsistent and in many cases what people liked to do included watching television, reading or listening to music. Some people were seen to be watching television or reading newspapers and others enjoyed the privacy of their own rooms. Visitors were seen to come and go through out the day and those spoken to were happy with level of care and said they know who to go to if they had any concerns. There continues to be a small activity room off the main lounge on the ground floor, where items for games and activities are held. Items available include games such as ‘bingo’ and ‘ludo’ musical instruments, playing cards, records and tapes and crafts. There continues to be very little information in the care plans that reflect people’s social needs. Where life history and past hobbies have been recorded there is no positive actions taken to follow these up. This means people are lacking stimulation and are not being given the opportunity to continue with past activities reducing their quality of life. There was a board displaying the day’s menu on the wall in the dining room information on the board included the days menu, which staff were on duty and the date. All the information was accurate. This is important for people with short term memory problems as it allows them to prompt their memory regularly. Menus are held in the kitchen for a four-week period. They were well balanced and showed that there is variety of choices, but did not show the availability of snack foods. The cook said that food orders and the menus are done at the sister home Chasewood Lodge. Therefore people in the home are excluded involvement in planning menus. On checking the food available there was a good supply of meat, fresh vegetables and fruit. There were also tinned goods and breads and fresh milk. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place records were available so there was evidence that people are protected. Staff training in protecting and safeguarding adults protects people from the risk of abuse. This judgement has been made using available evidence including a visit to this service EVIDENCE: The complaints policy continues to be on display by the front door to the home and is available to people. There have been three complaints these have been investigated by the home with outcomes. The records of the investigations of complaints and outcome letters sent to complainants were available and gave complainants satisfactory information on how the complaint had been investigated. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 17 Complaints were discussed with the person running the home and there appeared to be a common theme through them all the complaints appeared to be made worse in all cases by the way complainants had been responded to by staff at the home when they had voiced their concerns Staff appeared to be negative in their responses and not taking into consideration the feelings of the complainant. The home must review staff attitude and practice about concerns and complaints made directly to the home. It was recommended that some training be offered to senior staff so they have the skills to respond to people in a positive manner this could stop situations escalating. People spoken with, said they speak to staff when they have concerns. Other people indicated that they would tell someone if they were not happy. The staff training matrix read shows that staff have attended training in the Protection of Vulnerable Adults against Abuse (POVA). Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is homely and meets the needs of people who live there. Infection control procedures in place safeguarding people living in the home. EVIDENCE: The environment is homely warm and welcoming and meets the needs of the people who live there. People are encouraged to bring personal items in the home to make them individual and give the people using them a sense of ownership. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 19 People said they were able to go to their rooms when they wish and many have their own televisions and music systems. This allows people to have a choice in what they watch and listen to meeting their individual needs. The registered person continues to invest in the environment a programme of redecoration is on going with rooms being repainted with furniture and flooring being replaced. There are sufficient toilets and bathrooms on both floors these are close to communal area and have signs indicating what they are. This is important for people with dementia because they soon forget where things are. The laundry area has good systems of infection control. Soiled items of bedding and clothing are taken to the laundry in yellow clinical waste bags, the staff put on gloves and put their hands inside the clinical waste bag to empty clothing into the washing machine. There are red bags available for staff to launder soiled linen. There are also different coloured mops and buckets for cleaning different areas of the home. There was no odour from the laundry at the time of the inspection. There were two sinks one is a wash hand basin and the other a sluice sink. There was liquid hand soap and paper towels to wash and dry hands. Both areas were clean and tidy. There was a mop and mop bucket in the laundry yet the cleaner also confirmed that they do not mop the floor, and that this task is left to the night staff. Clothing was stored in racks there were no fire hazards at the time of the inspection. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels in the home meet the needs of the people who live there. Staff are trained to meet the needs of people and recruitment practices at the home, help to safeguard the people who live there. EVIDENCE: There was sufficient numbers of staff on duty at the time of the field visit and included three care staff one of which was a senior, one cleaner and a cook. The training matrix includes POVA, Caring for People with a Dementia, Moving and Handling, Diabetes, Emergency First Aid, Infection Control, Nutrition, Control of Substances Hazardous to Health (COSHH) and Continence Awareness. There continues to be a good training matrix in place, the records seen on the matrix and on individual files for three of the staff, does demonstrate that staff currently have the required skills to undertake their roles. There continues to be gaps in mandatory training including first aid, infection control, food hygiene, health and safety, moving and handling and medication. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 21 People also continue to undertake National Vocational training at levels 2 and 3. This makes sure that staff have the benefit of up to date training and have the skills to deliver good care. Some staff continue to attend ‘Yesterday, Today and Tomorrow’ training, which is accredited with the Alzheimer’s society. There are also planned training sessions called ‘Caring for People with a Dementia’ and ‘Behaviours we find difficult’. Nine staff files were seen all had checks undertaken by the Criminal Record Bureau. Application forms had been completed and references were on file. The recruitment practices at the home do help safeguard people from abuse. Relatives spoken with and comments received indicate that the staff group offer a good level of care to residents. On the day of the inspection the staff were noted to have a good manner with people and offered them care and support in a caring and compassionate way. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35 and 38 People using the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The procedures used to keep people’s money safe do not protect people from financial abuse. Records relating to fire tests were not available therefore the home cannot guarantee that people are safe. EVIDENCE: There has not been a registered manager at the home in excess of 12 months and the manager of the sister home is managing the home. This means she has to split her time between the two. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 23 There is evidence that the home has improved in some areas it’s quality of care but there is evidence that the home would benefit from a manager that could spend time in the home to develop the service and the staff team. The lack of consistent management oversight had led to a number of failures in the medication system had failed to make sure all the people’s health and well being was protected. The lack of risk assessment for one person and the failure to record the action and outcome of another placed those persons well being at risk. Systems for the safekeeping of monies was looked at there were a number of discrepancies that needed investigation. The system did not show clearly where the money had been spent and receipts were not always available. On a number of transaction sheets the money did not always balance. There was evidence that the system was audited withy the date and signature of the person doing the audit but this did not seem to pick up on the discrepancies. We were informed that there was a quality assurance system in place and the company has employed a consultant to review some of the systems in place. The manager said that the quality assurance has not been updated for some time. We said that the system should include views of people who use the service and those of their representatives on how the service could develop. Records of tests to the fire system could not be seen the registered individual said that they were at the other home. We informed the registered person that these records must be available in the home at all times. However there was evidence of good systems for fire evacuation. Records show how each resident would be best supported to leave the building in an emergency. A fire risk assessment was done in 2006 and this now needs updating, the training matrix shows that many of the staff have undertaken fire training in 2008 There was evidence available to show that the fire system and the emergency lights had been serviced in the past 12 months. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 24 The emergency call system, passenger lift and hoists have all been serviced regularly and all domestic electrical equipment have been PAT tested. There is a contract for the testing of water including temperatures and bacteria, this is completed quarterly and records are available all appears to be safe. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 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 3 3 X X 1 X 3 2 Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 13(1)(5) Requirement People’s moving and handling needs must be assessed to make sure that people are handled safety and reduce the risk of injury to both person and staff Where risks have been identified the registered person must make sure that staff follow the instruction for reducing the risk When new prescriptions are received the registered person must make sure that they are properly recorded on the administration sheet so that records are kept accurate. The registered person must make sure that there is an accurate and transparent system of records when safekeeping peoples personal monies The registered person must make sure that the fire alarm system is tested regularly to make sure people are safe from the risk of fire. Timescale for action 16/06/08 2 OP8 12(1)(b) 16/06/08 3 OP9 13(2) 16/06/08 4 OP35 Schedule 4 16/06/08 5 OP38 23(4)(a) 16/06/08 Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 27 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 4 Refer to Standard OP12 OP12 OP15 OP16 Good Practice Recommendations Information is included in the care plan about people’s lifetimes and experiences before they come into the home so that their diverse needs can be met Activities should be made more meaningful and organised taking into account people’s personal preferences and abilities People should be given an opportunity to be involved in the planning of menus. Senior staff should be offered training in managing complaints so they have the skills to respond to people in a professional and appropriate manner. Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chasewood DS0000004216.V363940.R01.S.doc Version 5.2 Page 29 - 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!