Inspection on 29/01/08 for Chatham House

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

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

Chatham House 28/09/09

Chatham House 08/10/08

Chatham House 31/07/07

Chatham House 13/09/06

Chatham House 15/12/05

Chatham House 24/06/05

Chatham House 01/02/05

Chatham House 06/07/04

Chatham House 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Chatham House Chatham House 44/46 Wembdon Rise Bridgwater Somerset TA6 7QZ Lead Inspector Kathy McCluskey Unannounced Inspection 29th January 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 Chatham House DS0000015985.V357168.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. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chatham House Address Chatham House 44/46 Wembdon Rise Bridgwater Somerset TA6 7QZ 01278 427758 F/P 01278 427758 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) MRS JESSIE JOAN POPE MRS JESSIE JOAN POPE Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st July 2007 Brief Description of the Service: Mrs Pope is both the Registered Provider and Registered Manager of Chatham House. Chatham House is situated in the residential area of Wembdon, 2 miles from Bridgwater town centre. The home is registered to provide personal care for up to 26 service users over the age of 65yrs. The home is not registered to provide nursing care, nor is it registered to provide dementia or other specialist care. Two large Victorian houses are linked by a modern annexe. There is car parking at the front of the house. To the rear there are extensive gardens with wheelchair access and handrails with a pleasant patio area. Accommodation is on two floors, comprising of 22 single bedrooms and 2 double rooms. There are 19 rooms with en-suite WC facilities, some have a bath (some not in use)/shower facility. TV points are available in each room. There is a passenger lift and two sets of stairs to the first floor, one with stair lifts. The communal rooms comprise of a very large lounge with three distinct seating areas, a smaller lounge and an adequately sized dining room. There are three payphones in different locations in the home, plus the use of a mobile phone for incoming calls. There is a call system fitted to all areas of the home. The home’s current fee range is between £370 & £390 per week. Additional charges include: chiropody, personal toiletries, hairdressing, newspapers/magazines and some personal care products. Chatham House DS0000015985.V357168.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service for each outcome group under four general headings. These are; - excellent, good, adequate and poor. The home’s last key inspection was conducted on 31st July 2007. Following concerns raised at that inspection, a further inspection was carried out on 27th September 2007. The registered provider was also invited to attend the Commission’s office in Taunton to discuss the plans for improvement. This unannounced Key inspection was conducted over one day (7hrs) by CSCI Regulation Inspector Kathy McCluskey. The registered provider/manager was available throughout the inspection and the deputy manager was available for part of the inspection. At the time of this inspection, 20 service users were living at the home and the inspector was able to spend time talking to a number of service users. All communal areas and a selection of bedrooms were viewed during this inspection. Records relating to staff, service users and health and safety were examined. The inspector would like to thank service users, staff and management for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? At the home’s last key inspection 13 requirements were raised and the registered person was required to submit an improvement plan to the Commission. An additional visit was made to the home to monitor compliance. At this inspection there was evidence that some improvements had been made to the home’s care planning systems. Care plans were up to date and contained information about the individual’s assessed needs and preferences. Further improvements are needed to ensure that clear instructions are documented for staff as to how the assessed needs should be met. Records are now being maintained which identify service users contact with appropriate healthcare professionals. With the input of service users, the home’s programme of activities has been reviewed and is now displayed for service users in the lounge. Service users spoken with were positive about the activities available. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 7 The registered person has sought the advice of a dietician and has made appropriate changes to the menus. Service users stated that the food was good and that there was always plenty to eat. The home’s complaints procedure has been updated and is now displayed in the reception area of the home. Service users did not raise any concerns with the inspector and said that they were discussing concerns with the home if they had any. Staff have now received training in the prevention of abuse and appropriate, up to date policies are available in the home. The home is now following the correct procedures for staff recruitment and newly appointed staff now follow an appropriate induction programme. All staff have now received up to date mandatory training and the home took appropriate steps to ensure that all moving and handling equipment had up to date servicing certificates. 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. The summary of this inspection report can be made available in other formats on request. Chatham House DS0000015985.V357168.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 Chatham House DS0000015985.V357168.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, 3, 4 & 5 Standard 6 is not applicable, as the home is not registered to provide intermediate care. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to enable them to make an informed choice about moving to the home. The home ensures that prospective service users are assessed prior to a placement being offered. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a Statement of Purpose and Service user Guide that are contained within the home’s brochure. The Commission have not been advised of any changes to these documents since the last inspection. The inspector was able to meet with a service user who had recently moved to the home. The service user confirmed that before moving to the home, they were visited by the registered provider/manager where their needs were discussed. The service user visited the home with family members prior to making a decision to move there. Care plans examined contained evidence of pre-admission assessments. Assessments and care plans from other healthcare professionals had also been obtained where available. The induction programme for newly appointed staff has been improved and this now covers appropriate topics to ensure that staff have the skills to meet the needs of service users. Service users spoken with during this inspection indicated that their needs were met by staff and that their preferences were respected. Chatham House DS0000015985.V357168.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 & 10 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home have made some improvements in the care planning systems but further improvements are needed. The home’s procedures for the management and administration of service users medication are generally good. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 12 EVIDENCE: At the last key inspection the home was required to update their care planning systems to ensure that individuals assessed needs were clearly identified and that clear instructions were available for staff as to how individuals needs should be met. It was also required that care plans promoted a person centred approach to care and that they are reviewed at least monthly. Two service user care plans were examined at this inspection and although some improvements were noted, further improvements are needed. On examination of available assessments, it appeared that care needs had been identified and that the preferences of the individual had been included as appropriate. Instructions for staff on how assessed needs should be met are still lacking sufficient information. This was discussed in detail with the registered provider/manager at the time of the inspection. Since the last inspection the registered provider/manager has introduced a new care planning system but is planning to review this again. Basic risk assessments were in place relating to falls, nutrition and moving and handling. There was evidence that care plans are being reviewed at least monthly. The registered provider/manager showed the inspector completed forms, which identified basic care needs and preferences, which she stated was completed with the service user when they moved to the home. It is recommended that this form is signed by the service user. Service users spoken with felt that staff were currently meeting their needs. ‘They know what I like and how I like it’, I am happy here and don’t have any concerns’. As required at the last inspection, the home is now maintaining records pertaining to individuals contact with healthcare professionals. Service users are weighed on a monthly basis. The inspector examined the home’s procedures for the management and administration of service users medication. The home uses the Boots monitored dosage system (MDS) with pre-printed medication administration charts (MAR). Medicines were seen to be securely stored. MAR charts were examined and the inspector noted that hand written entries had not always been confirmed with two staff signatures. To reduce the risk of errors, it has been recommended that any hand transcribed entry on MAR charts is confirmed with two competent staff signatures. This was also recommended at the last inspection. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 13 The registered provider/manager stated that she was in the process of arranging updates for staff in the management and administration of medication. Progress will be followed up at the next inspection. Service users spoken with indicated that staff respected their privacy and that they were satisfied with how staff assisted them to meet their personal care needs. Service users have access to a telephone and screening is in place in shared bedrooms. Chatham House DS0000015985.V357168.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 & 15 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users can choose how to spend their day and the provision of activities has improved. The home welcomes visitors in line with the preferences of service users. Menu options have improved and now provide more nutritious and varied meals. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 15 EVIDENCE: At the home’s last key inspection it was required that after consultation with service users, the home develops an appropriate programme of activities. A further inspection was conducted and there was evidence that this had been addressed. At this inspection a programme of activities was on display for service users and people spoken with indicated that they were satisfied with the activities available. Several service users stated that they enjoyed the bingo and quizzes. ‘It’s pretty good here and I like the bingo and raffles’, ‘the trips out are good’. A hairdresser visits the home on a weekly basis and trips out are offered twice a week in the home’s mini bus. Some service users were out on a trip during the inspection. As recommended at the last inspection, the home maintains individual records for service users relating to activities. Outcomes are recorded. Care plans examined contained individual’s social history. Service users spoken with confirmed that they could choose how and where to spend their day. During the inspection the majority of service users appeared to be utilising the large lounge area. Some were watching the television, some were reading the daily newspapers or books and some were enjoying a chat with another service user. The atmosphere was relaxed. Service users confirmed that they could choose what time to go to bed or get up in the morning. The inspector did not meet with any visitors during this inspection but service users confirmed that their visitors were always made to feel welcome. ‘I can have who I like to visit me and they are always made welcome and given a cup of tea’. Service users did not raise any concerns about the meals available at the home. ‘The food is good and there is always plenty to eat’, ‘we can have anything we like for tea’, ‘we can have a snack when we like’, ‘they know what I like’, ‘there are lots of choices for breakfast’. Following a requirement raised at the last inspection, the registered provider/manager made arrangements for a dietician to visit the home and review the home’s menus. A detailed report was made available to the inspector and there was evidence that the home had taken action to address the dietician’s recommendations. Menu options appeared varied and made good use of fresh vegetables and meat. Chatham House DS0000015985.V357168.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 & 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home now displays a satisfactory complaints procedure. The home has taken appropriate action to reduce the risk of harm or abuse to service users. EVIDENCE: During an additional inspection of the home, the inspector was able to see evidence that the home had taken action to address the requirement raised at the home’s last key inspection. An appropriate complaints procedure in now displayed in the reception area of the home. The registered manager/provider stated that the home had not received any complaints since the last inspection. No concerns have been raised directly with the Commission. Service users spoken with during the inspection did not raise any concerns with the inspector and stated that they would discuss any concerns should they have any. As required at the last inspection, the home has taken action to provide all staff with training in the prevention of abuse. This took place in October 2007 and certificated evidence was seen in staff records examined. The home now has a copy of Somerset’s Policy (May 2007) on Safeguarding Adults. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 25 & 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable, homely environment and the home is well maintained. The standard of cleanliness is good and the home takes appropriate steps to reduce the risk of the spread of infection. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 18 EVIDENCE: Chatham House consists of two large Victorian properties, which have been linked together to provide accommodation for up to 26 service users aged 65yrs or over. The home promotes a ‘homely’ feel, which was also confirmed by service users spoken with. The home has a range of communal space, which includes a very spacious lounge, which has patio doors and views over the garden. This lounge is arranged into three distinctive areas. The majority of service users were seen to be utilising this area on the day of the inspection. A smaller lounge is also available. There is a good-sized dining room, which looks out at the front of the house. The home has interesting and extensive gardens to the rear, which are accessible to wheelchair users. Ramps and grab rails are appropriately sited. Garden furniture is available. Car parking is available at the front of the property. Grab rails and ramps are appropriately sited. A nurse call system is installed in all bedrooms and communal areas/facilities. Service users spoken with confirmed that call bells were answered promptly. Service user accommodation is arranged over two floors with a shaft lift and stair lift providing access for those who are unable to manage stairs. There are 22 single bedrooms and 2 doubles. 19 bedrooms have en-suite toilet facilities. Some are fitted with a shower/bath. Screening is available in the shared bedrooms. Service users spoken with informed the inspectors that they liked living at Chatham House and were very satisfied with their bedrooms. Bedroom doors are fitted with a lock, which can be over-ridden by staff in the event of an emergency. The home has an assisted communal bath and level access shower in addition to en-suite facilities. As required, service users have their own mobility aids/wheelchairs. The home has one mobile hoist and one stand-aid. All areas of the home seen benefited from natural light. To ensure the health and safety of service users, radiators are fitted with a guard; wardrobes secured to the wall and upstairs windows are restricted. Hot water outlets are fitted with thermostats to reduce the risk of scalding. On the day of this inspection the home was clean and free from malodours. Hand washing facilities are appropriately sited in the home. Staff have access to protective clothing. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 19 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, 29 & 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Staffing levels appear appropriate to the needs and numbers of service users currently living at the home. The home follows the correct procedures for staff recruitment. The home’s arrangements for staff induction and training have improved. EVIDENCE: At the time of this inspection 20 service users were living at the home and the registered provider/manager stated that current staffing levels were as follows; Morning – 4 care staff Afternoon/evening – 3-4 care staff Night – 2 waking care staff. In addition to care staff, kitchen and domestic staff are on duty. The home also employs a maintenance person/gardener. The registered provider/manager and deputy are at the home in addition to care staff and also provide on-call cover. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 20 The inspector was informed that the home currently has vacancies for a part time night carer and a cook. The home is not using agency staff. Shortfalls are currently being covered by existing staff. Service users and staff did not raise any concerns during this inspection regarding staffing levels at the home. As previously mentioned in this report, service users stated they were satisfied with the care they received and felt that their needs were met. The inspector was informed that two care staff had been recruited since the last inspection. Recruitment records for these two staff member were examined at this inspection. Both contained all required information including evidence of an enhanced criminal records check (CRB) and Protection of Vulnerable Adults check (POVA). Both had been obtained prior to the employee commencing employment. Records were noted to be more organised. Action had been taken to address the requirement relating to staff training. Staff training records contained evidence that staff had received appropriate mandatory training, training in abuse and care of people with dementia. The deputy manager now maintains clearer records relating to staff training, which includes the date completed. The deputy manager stated that with this recording system, she felt confident that training updates would be arranged as required. There was evidence that the recently appointed staff members were currently undertaking a period of induction. As recommended at the last inspection, the induction programme has been reviewed and now follows the recommendations of the Skills for Care Common Induction Programme. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 21 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, 33, 36 & 38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a stable management team. Quality assurance systems are in place but do not currently seek the views of service users. Formal systems need to be in place to ensure that staff are appropriately supervised. Procedures relating to health and safety and mandatory training have improved. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 22 EVIDENCE: Mrs Pope has owned and managed Chatham House since 1983 and has considerable experience in caring for the elderly. Mrs Pope is currently working towards the Registered manager award. Mrs Pope is supported by her daughter Ms P.Hall. Both are present at the home on a daily basis and take very much a ‘hands on’ approach to the care of service users. The home has a quality assurance programme, which seeks the views of relatives. At the last inspection it was recommended that systems were also introduced to seek the views of service users. At this inspection the registered provider/manager stated that she planned to send out service users comment cards this year. Progress will be followed up at the next inspection. The registered provider/manager also stated that service users are encouraged to express their views on a daily basis. Comment cards were last sent to relatives in April 2007. A selection were examined at the last inspection and comments were found to be very positive. Staff appraisals are carried out annually. Both the registered provider/manager and deputy informed the inspector that they met regularly with staff but that these one-one meetings were not formally documented. The registered person must take appropriate action to address the requirement of the last inspection to ensure that staff are appropriately supervised and receive formal supervision sessions at least six times a year. Records must be maintained and topics discussed should be in line with the recommendations set out in the National Minimum Standards. The homes records were examined relating to health & safety. A tour of the premises was also carried out. FIRE SAFTY – Records demonstrated that in-house weekly checks are made on the home’s fire alarm systems. Monthly checks on emergency lighting had not taken place since July 2007. The inspector was informed that this was due to an oversight by the new maintenance person and would be addressed. Fire equipment was last serviced on 09/02/07. As required at the last inspection, staff received up to date training in fire safety in September 2007. ELECTRICAL SAFETY – Annual servicing on the home’s portable appliances was found to be up to date. This was last recorded as June 2007. The home has an up to date electrical hard wiring certificate. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 23 EQUIPMENT SERVICING – Servicing records for the home’s passenger lift, stair lift and bath aids were found to be up to date. An immediate requirement was issued at the last inspection as servicing for the home’s two mobile hoists were out of date. Appropriate action was taken and evidence was forwarded to the Commission. ACCIDENTS – The home maintains appropriate records for accidents. As recommended at the last inspection, findings are now analysed on a monthly basis and provide the home with useful information on any traits. As required at the last inspection, the home is now informing the Commission of any events as stated in Regulation 37 of the Care Homes Regulation 2001. COSHH – At the time of this inspection, all cleaning materials and items hazardous to health were found to be appropriately stored. HOT WATER OUTLETS – The inspector was informed that all bath hot water outlets had been fitted with a thermostatic control. Warning signage was in place over wash hand basins. Monthly checks are conducted to ensure that temperatures to not exceed recommended safe upper limits. To ensure the safety of service users, radiators are guarded, wardrobes are secured to the wall and upstairs windows are fitted with a restrictor. STAFF TRAINING – The registered provider/manager has taken appropriate action to address the requirement of the last inspection relating to mandatory training for staff. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 24 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 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x N/A 2 x 3 Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15(1) Requirement The registered person must ensure that service user care plans contain clear instructions for staff on how individuals assessed needs should be met. Timescale for action 29/02/08 2. OP36 18(2) The registered person must make suitable arrangements to ensure that staff are appropriately supervised. Formal supervision sessions for staff should take place at least 6 times a year with records maintained. Previous timescale of 30/10/07 not met. 10/03/08 Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 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. 2. Refer to Standard OP7 OP9 Good Practice Recommendations The registered person should ensure that service users sign their care plans as appropriate. The registered person should ensure that hand transcribed entries on service user Medication Administration Records (MAR), are confirmed by two staff signatures. This was raised at the last inspection. 3. 4. OP38 OP9 The registered person should ensure that the home’s emergency lighting is tested by a competent person at monthly intervals. The registered person should ensure that all staff involved in the management and administration of service user medication receive appropriate up to date training. Chatham House DS0000015985.V357168.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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