Inspection on 24/05/05 for Chatterley House

This inspection was carried out on 24th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chatterley House 12/02/09

Chatterley House 03/05/07

Chatterley House 21/11/06

Chatterley House 02/05/06

Chatterley House 09/02/06

Chatterley House 14/12/04

Chatterley House 02/08/04

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Polesworth Group 70 Long Street

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10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Chatterley House Chatterley Road Tunstall Stoke on Trent ST6 6PX Lead Inspector Irene Wilkes Announced 24 May 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Chatterley House Address Chatterley Road Tunstall Stoke on Trent Staffordshire ST6 6PX 01782 834354 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) Ms Alice Clark Ms Teresa Sloan Care Home 9 Category(ies) of 9 LD registration, with number of places Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 December 2005 Brief Description of the Service: Chatterley House is a care home registered for nine people with a learning disability. 6 gentlemen and 1 lady currently live at the home, and there are 2 vacancies. The home is a detached property set in its own grounds. The proprietor’s house is also situated within the same grounds, and this allows good access and daily contact with the care manager and the service users.The home is situated just outside Tunstall, which is one of the towns that make up the City of Stoke-on-Trent. It has good access by road, but although there is public transport from other areas to Tunstall itself, bus routes do not extend to the home’s location. A mini bus is provided to address this.There are few local facilities in very close proximity to the home, although a pub is within walking distance which one or two of the service users use. Tunstall, however, has the range of shops that you would expect of a small town. Chatterley House has five single bedrooms and two double bedrooms. There are spacious communal rooms that are attractively furnished. All areas of the home are generally well maintained.The grounds have attractive gardens and adequate space for car parking. There are links with local colleges and day services to provide service users with opportunity for personal development. There is also a focus on community presence and service users enjoy a range of holidays of their choice. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a whole day by 1 inspector. A tour of the home and gardens, including 3 service user’s bedrooms was undertaken. 3 service users, 2 care staff, the proprietor and a visitor were spoken to. The manager was not available due to annual leave. 3 care plans and a staff file were examined. Information from the files was cross-referenced with service users and staff views to further confirm the evidence available in the files. Other documents relating to staff training, food choices, medication and maintenance records were also looked at. Staff practice, including staff and service user interaction was observed throughout the inspection. What the service does well: The 3 gentlemen who were spoken to said that they were happy living at the home and that the staff treated them very well. The service users each have a lifestyle based on their own choices and decisions, with guidance from the manager and staff as appropriate. The gentlemen said that apart from the tasks that each had agreed to do as part of the responsibilities of communal living they pleased themselves about what they did in the home. ‘I please myself when I go to bed; its when I feel like it. The food’s all right. If I don’t want something I can choose something else.’ This freedom of decision was confirmed by a visitor who said that she was well known to all of the service users and if they saw her arriving someone would put the kettle on for a cup of tea and sit and have a chat with her. She felt that this showed that the service users were relaxed and at ease in their own home –‘ a real home in the true sense’ was how she described it. Full attention is paid to the health needs of the service users. Each attends a well woman/well man clinic as relevant and other health appointments with the GP, chiropody, dental and any other physical or mental health specialists are kept as required. There are safe systems in place for the storage and other aspects of medication. 2 of the service users self medicate and there are risk assessments in place to cover this. Medication procedures are sound and all of the staff have received training in the safe handling of medication from a pharmacist. The service users spoken with felt that the staff listened to them and sat regularly with them to talk on an individual basis about their lives and any issues. Minor grumbles are timely and appropriately dealt with to prevent escalation of any problem areas. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 6 Chatterley House provides a lovely environment for the service users. It is spacious but with a homely feel, and the proprietor does her utmost to provide both pleasant and comfortable surroundings. The spacious conservatory has just been upgraded and the service users are very pleased about the addition of a pool table and table football game that have been brought in from the summerhouse in the grounds. The home has a committed staff team and it was clear from staff and service user interactions and from what the service users said that there is a good rapport between them, and that the staff have a good understanding of each individuals’ needs. What has improved since the last inspection? What they could do better: While there is a care plan in place for each service user and this is discussed on an individual basis with each of them, the plans do not always consider the aspirations of the service users or show that the home is working in a planned way with them to meet these goals. Future discussion should focus more on these aspects. Whilst the home has a committed staff team, issues associated with the efficient and effective staffing of the home is an area that requires some improvement. Attention must be paid to ensure that the home is appropriately staffed at all times, including when some of the staff team are on holiday or absent through illness. Recruitment records must also be more complete so that if staff commence at the home undertaking induction only with the manager before the receipt of the Criminal Records Bureau or Protection of Vulnerable Adults (POVA) check is received, this must be recorded in the staff file to show that regulations regarding checks have not been broken. None care staff must not be left in charge of the home. All of these issues must be addressed. While staff training is evident for both mandatory and other training, the home must ensure that staff are paid for any training sessions attended. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 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. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 4 Prospective service users are encouraged to visit to see if the home will suit their needs before a decision is made to move in permanently. EVIDENCE: A requirement was made at the last inspection visit for the Statement of Purpose and Service User Guide to be improved to contain current information about the home. This had been addressed and each service user had been given their own copy of the guide. There are currently 2 vacancies in the home and care staff said that 2 prospective service users had visited on a number of occasions, culminating in an overnight stay very recently. The service users spoken with also said that 2 people had visited the home and they had shown them around and helped them to find things. There was no paperwork available regarding these visitors to the home. The 7 permanent service users have lived at the home for some time now, and inspection of their individual files at this and previous visits showed that their individual needs had been assessed. Hopefully the 2 vacancies will have been filled by the time of the next visit enabling an inspection of their files to determine if best practice has been followed. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The home consults with service users about their needs and lifestyle and supports them in their decisions, taking into account and planning with them the actions to take for any risks that may arise. Some discussions are needed with some of the service users about their aspirations for the future and how these goals may be met. EVIDENCE: There was opportunity to have a full discussion with 2 service users and a more limited conversation with a third young man living at the home. The other 4 residents, 3 gentlemen and a young woman were all out at either work or the Day Centre. One of the gentlemen talked about discussions that he had with staff about his life and plans, and knew about his care plan and what it contained. He said that he sat down in the office regularly to discuss things and that staff asked him if he was happy for this to be written down, and then he signed it. His care plan contained appropriate information about his needs and lifestyle, there were satisfactory risk assessments in place for accessing the community alone and interactions with others, but there was a lack of focus on personal goals and aspirations. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 11 Another service user was happy to chat and said that he was very contented with his life and didn’t want anything to be any different. He has lived at the home for many years now and said that he was happy ‘just doing his own thing.’ His key worker was on duty and said that the gentleman never wanted to discuss his care plan or do anything any different; he said he was contented just reading his newspapers and magazines, going to the pub when he felt like it and watching the TV with the other residents. His care plan confirmed this, and further discussion with him strongly suggested that he was indeed perfectly happy with his way of life. Previous discussions with other service users and inspection of their care plans also supports that their needs are fully discussed with them. Greater discussion may perhaps show any aspirations for the future that they may have. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17 Service users lead a lifestyle of their choice and engage in appropriate activities both within the home and in the wider community. They enjoy their meals in congenial surroundings. This leads to service users being contented with their lives and feeling that they are in control of what they do. EVIDENCE: Conversation with the 3 service users who were at home showed that they enjoy a fulfilled lifestyle appropriate to their interests and abilities. One service user spoke about his work at a sheltered employment centre, and about his girlfriend and other friends who work there. His leisure time is spent with his girlfriend and they exchange visits to each other’s home as they choose. He also attends a centre for people with disabilities on a Wednesday evening for social activities, and he talked about going to the pub with his girlfriend after work occasionally for a meal and a shandy. He uses a bus pass for travel independently, and said that he sometimes also used a taxi if he was in a hurry or if funds allowed. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 13 Another service user who is somewhat older leads a less busy and active life, but nevertheless said that he was perfectly contented pottering around the home and being a regular at the local pub, mainly at a lunchtime, where everyone knows him. The third service user who was spoken to has also chatted before about his lifestyle. He prefers to wander up to the local shops and play his music when he is in the home, but he does participate in trips out with the others to the theatre and out for a meal when he wishes. The care plans for the three service users were seen and they built up the picture further of the type of lifestyle that each person enjoys, and supported that the right of the service user to choose what they want to do is recognised, with guidance and support given by staff on an individual and regular basis. A visitor came to the home and kindly agreed to chat about her views on the home and what she had seen of the lifestyles of the service users. She works as a guide on the bus that takes 3 of the service users to the adult training centre. She talked about the fulfilling lifestyle that the service users seem to enjoy, and said that she felt that Chatterley is a home in the true sense of the word, with residents very relaxed and able to ‘do their own thing.’ She said that if any of them saw her arriving to visit they would go and make her a cup of tea and sit down and have a chat, which she felt illustrated the fact that they could choose for themselves what they did in the house. Meals and mealtimes were also discussed and the menu book seen. The menus showed a varied and nutritious diet is provided, and the service users said that they enjoy their food. An alternative choice was confirmed as being provided if something was on the menu that they didn’t feel like. There is a dedicated pleasant dining room that opens out on to a conservatory where the proprietor has installed a pool table and a table football game. The service users all said that they really enjoy the benefit of these games being available and have competitions in the evening following their meal. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 All aspects of service users’ health needs are recorded and met, and the home has sound procedures in place for the administration of medication. This attention to individual needs leads to early intervention by health professionals if any health problems are experienced. EVIDENCE: The service users currently living at Chatterley House are all quite independent in personal care and just require prompting to undertake their own personal care tasks. Those spoken with said that they had the support that they need and staff are always available if they want them for advice or to assist on occasions. The care plans inspected showed appropriate recording of all health appointments, health checks, issues and outcomes for each service user. Well man/well woman health check appointments are kept, and appropriate referrals to other health professionals take place as required. 2 of the service users self medicate. There is an appropriate medication procedure in place, and a risk assessment was seen for each service user regarding self-medication. One of the staff on duty discussed the procedure followed both for the service users who self medicate and for those for whom the home administers medication. These procedures were satisfactory. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 15 The service users who self medicate have a lockable storage facility for this in their bedrooms. The storage of other medication is in a locked cabinet in the office, which is also locked when the manager and staff are elsewhere in the home. These arrangements are satisfactory. Medication is received from the pharmacy in individual dosette boxes. There is a document available in the medication file that has been signed by the G.P. for the administration of all ‘as and when required’ medication for each service user. The home does not use homely remedies. All records for the receipt, administration and return of surplus medication were appropriate. All of the staff currently working at the home have received training in good practice regarding medication from the local pharmacist. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The Complaints Procedure shows clearly how any complaints will be addressed, and the timescale that will be followed. Current service users know from experience that they can raise concerns at any time and that their views will be listened to by staff. EVIDENCE: The home has a Complaints Procedure in place, and there is an individual copy kept in each service user’s file. Discussion with the service users evidenced that they have regular meetings with their key worker when they are encouraged to raise any issues or concerns, and that the staff work with them to address any problems. Minor grumbles about day to day living with others are addressed in a timely way to prevent escalation of any problems. The service users said that they had no problems in raising anything that they were not happy with, and that the staff always listened. A discussion with a key worker also showed that she had the welfare of the service users at heart, and discussions that she had held with service users were recorded in the individual care plans. This was also evidenced in other service user files, and in the weekly contact sheets. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 , 27 and 30 Chatterley House provides a safe and homely environment for the service users where every effort is made to meet their needs for a comfortable and pleasant home. The home is very clean, but further attention needs to be paid to infection control to protect service users and staff as far as possible from the spread of any infection. EVIDENCE: Chatterley House is a very pleasant home. It provides spacious and safe accommodation for 9 service users in a domestic style with comfortable furniture and fittings and good décor in a very homely environment. There is a spacious lounge, separate dining room with a large conservatory off, well equipped kitchen and laundry and sufficient bathrooms for 9 service users, with 5 single and 2 double bedrooms that are well furnished. The grounds are spacious and well cared for, and there is a summerhouse also in the grounds that the residents can use as an alternative sitting area if they so choose. The large conservatory has recently been upgraded with a new floor and furniture. A pool table and a large table football game have been purchased, and these provide at home entertainment that is proving very popular. 2 service users who were at home spoke about playing pool in the evenings, and Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 18 the third said that although he didn’t personally choose to play he was enjoying watching the others. The last inspection recommended that an upstairs bathroom be redecorated as the paint was peeling from the walls etc. and it was looking shabby compared with the rest of the house. The proprietor has not only taken these comments on board, but has chosen to re-fit the bathroom completely, and work was in progress on the day of the visit to complete this. A new large downstairs shower has also been fitted since the last inspection, and these together with an assisted bath provide the service users with a good choice of bathing facilities to enable them to maintain their independence. The home now needs to use liquid soap and a wall fitment for paper towels for hand washing to help prevent cross infection. These items are also needed in the staff toilet. A tour was made of the communal areas of the home and a number of bedrooms. Everywhere was very clean. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 35 There is a small but committed staff team with a commitment by the home to NVQ training. However, staff do not receive payment for undertaking training on every occasion, and this must be addressed. The health, safety and welfare of the service users must be better assured by the availability of appropriately trained, vetted and adequate numbers of staff at all times, the latter determined following a risk assessment process. EVIDENCE: In addition to the manager there is a small stable staff team of 6, and 5 of these staff are qualified to NVQ 2 or above, which is very pleasing to note. Various staff have been spoken to at different inspections, and they are all keen to undertake training to help them to provide the best service possible. The staff file of the newest staff member was inspected. This showed a clear CRB check dated for early November 2004, but other records showed that she had commenced working in the home in early October 2004. Recruitment records must be more complete so that if, as on this occasion, staff commence at the home undertaking induction only with the manager before the receipt of the Criminal Records Bureau or Protection of Vulnerable Adults (POVA) check is received, this must be recorded in the staff file to show that regulations regarding checks have not been broken. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 20 A training matrix was available and this showed that all staff had at some point received training in food hygiene, health and safety, basic first aid, medication training, fire safety and infection control. However, there were no dates attached to these records and so it was not possible to determine if the mandatory training was up to date for all staff. Dates when training took place should be added, together with a record of when refresher training is due. There has previously been a requirement that staff should receive training in behaviours that challenge. This training has still not taken place. As this was required particularly to meet the needs of 2 service users who are no longer living at the home this may have been considered not now as pressing, but nevertheless it is recommended that this training should still take place to meet best practice in the home. Discussion with staff regarding training found that whilst staff have access to mandatory and other training they do not always receive paid training. The standards state that staff should be provided with at least 5 training and development days per year. A plan of training, with timescales, must be provided showing how the home will work towards meeting this requirement, with an assurance that staff will receive payment for all training undertaken. There have been concerns in the past regarding the small number of staff available. This is compounded by the fact that the staff team also cover another home for 2 service users that is close by. These service users spend part of their week at Chatterley House because of the staffing issues. At this visit there was only 1 member of staff on duty at Chatterley House due to holiday leave of the manager. 4 service users were out, and there were 2 vacancies. The staff member said that this did happen on occasions because of holidays but that the staff team had no problems with these staffing arrangements. It must be stated that the needs of the service users at present are low, but the concern is that the health and safety of the service users and the staff member could be compromised should any untoward incident take place. This could be exacerbated further once the 2 vacancies are filled. The home must undertake a risk assessment on each occasion when only 1 member of staff is planned to be on duty, to determine in each given situation whether the health and safety of the service users can be adequately addressed, and action must be taken accordingly. In addition the home must have very clear procedures that all staff understand about what they need to do should an emergency occur when they are on duty alone, to protect the best interests of all the service users. A discussion with a service user who arrived from the other home to spend the day at Chatterley stated that on an occasion recently the 2 service users had come to the home to sleep because of the unavailability of staff to cover their Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 21 home overnight. Additionally, on another occasion the handyman had covered a shift at their home because of a lack of staff. The staff on duty at the visit said that they had no knowledge of this, but the proprietor later confirmed these events. The home must ensure that there are sufficient staff available at all times to adequately provide for the health and safety of the service users at both homes. The home may need to employ agency staff to cover shifts if there is no other alternative cover available to staff the homes. The manager must ensure that the handyman has an enhanced Criminal Records Bureau check if this has not already been addressed, as he spends some considerable time with service users and also drives the home’s transport. The practice of his covering shifts for staff must cease unless he becomes a member of the care staff team. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 As the home has not undertaken any review of the quality of the services that are provided, service users’ views about the further development of the home have not been sought. Attention is paid to maintenance and other safety checks towards ensuring that the requirements for health and safety are met. However, staffing rotas must be linked to a risk assessment procedure and the outcome acted upon in order for the home to properly satisfy itself that the health safety and welfare of service users are promoted and protected to the optimum level possible. EVIDENCE: Service users spoken to said that the home consulted them about life in the home on a general basis, such as evenings out, holidays etc. There are occasional house meetings but the manager has in the past said that the service users prefer 1:1 consultation about issues, and the 2 service users who were asked confirmed this. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 23 Whilst the home has previously sent out an occasional satisfaction questionnaire about aspects of the home to relatives, this has not yet been undertaken with service users. The home has neither undertaken any self monitoring of where they are at in terms of review of their services and development of the home, and a way must be found to do this and to also involve service users in the process. A sample of maintenance and other records relating to health and safety issues were seen. There was a current gas safety certificate, testing of fire extinguishers was up to date, the insurance certificate for employers liability insurance was up to date, and the fire alarm system had been timely tested. Control of Substances Hazardous to Health (COSHH) materials were suitably stored in a locked cupboard and each substance had a relevant data sheet in place. The home’s attention is drawn to the requirements of section 37 requiring the Commission to be informed of any death, outbreak of infection or serious injury to a service user among other notifications. A serious injury had occurred to a service user and the Commission had not been so notified. Issues regarding staffing that could impact on the health, safety and welfare of the service users have been addressed elsewhere in the report. Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 1 3 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chatterley House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 Requirement Address the individual aspirations of each service user and ensure that these are recorded in their care plan Provide liquid soap and paper towels and dispensers at all hand washing facilities Ensure that there are sufficient numbers of trained care staff on duty at all times Undertake a risk assessment when planning staff rotas to determine if it is safe at that time if only 1 member of staff is to be on duty Anyone in charge of the home at any time must be a member of the care staff team. Ensure that the training matrix shows the dates when training was completed and also for when any refresher training is due Ensure that staff receive payment for all training attended Provide a plan of training needs for all staff, with timescales, showing how the home will work towards providing 5 paid training days per year per staff member Commence a review of the services provided by the home Timescale for action 31/8/05 2. 3. 4. 30 33 42 13(3) 18(1) (a) 12(1) (a) 31/8/05 ongoing As required 5. 6. 33 35 18(1) 18(1)c ongoing 31/8/05 7. 8. 35 35 18(1)c 18(1)c 31/8/05 31/8/05 9. 39 24 31/8/05 Page 26 Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 10. 11. 12. 13. 14. 15. 16. 42 37 and involve the service users in these procedures Notify the Commission in writing of any Section 37 incidents ongoing 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 35 Good Practice Recommendations Provide training in behaviours that challenge (thiis was a requirement from the previous inspection of December 2004 that had not been met. Service user needs have changed in the home, but it is recommended that this training still takes place Chatterley House E51-E09 S8209 Chatterley House V229329 240505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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