Inspection on 18/10/07 for Chatterwood Nursing Home

This inspection was carried out on 18th October 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chatterwood Nursing Home 21/09/06

Chatterwood Nursing Home 03/02/06

Chatterwood Nursing Home 20/07/05

Chatterwood Nursing Home 16/02/05

Chatterwood Nursing Home 13/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Chatterwood Nursing Home Huntsbottom Lane Hillbrow Liss Hants GU33 7PA Lead Inspector Gina Pickering Unannounced Inspection 18th October 2007 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 Chatterwood Nursing Home DS0000038996.V347442.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. Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chatterwood Nursing Home Address Huntsbottom Lane Hillbrow Liss Hants GU33 7PA 01730 895485 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) Milkwood Care Limited Mrs Joyce Gilfroy Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (24), Physical disability of places over 65 years of age (24) Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user under the age of 55 is to be admitted. Date of last inspection 21st September 2006 Brief Description of the Service: Chatterwood offers nursing for 24 residents over the ages of 55 years. There are five shared bedrooms and thirteen single, nine of which have en-suite facilities. There is a large communal area that is divided into four separate areas, lounge areas and dining areas, and the home has a shaft lift. There is a very large garden at the front of the home, which is not easily accessed by the residents because of the steep sloping paths and there is a large patio, which is accessed via the conservatory. The home is in a rural area and the local shops in Liss are accessible with assistance. The Commission was informed that the current fees for the home are £442 £700 per week, with additional charges for hairdressing, chiropody and newspapers for which the residents are individually invoiced. . Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection considered information received by the Commission about the home since the last key inspection in September 2006. This includes information provided to us in the form of the home’s Annual Quality Audit Assessment form in which the registered provider or manager tells the Commission how the service has developed over the past twelve months and how they propose to continue to improve the service. The Commission surveyed service users, relatives and staff; the information in these was used to inform the inspection. An unannounced visit was made to the home on 18th October. Four service users were case tracked, looking at documentation relating to them, and speaking with the service users. Conversations were held with a further three service users, five staff members and the group manager as well as touring the home and looking at various documentation as part of the inspection process. The registered manager was not available during the visit to the home. Surveys received by the commission from service users, relatives, staff members and a GP all made favourable comments about the service provided by Chatterwood. Comments from relatives include ‘everyone is friendly and helpful and kind making for a happy home. Joyce (the matron) is a great matron of a good team’, staff are ‘very caring and attentive’, and ‘ I am very satisfied with the care my relative receives form the staff/management.’ Comments from staff include ‘it provides a homely environment for all the service users. all service users are respected and offered choices’ and ‘the manager meets me and discusses matters concerning the running of the home and supports me.’ And from a GP ‘ very individualised care, look after the whole person and act appropriately to next of kin enquiries’. What the service does well: A good pre admission process ensure that service users are confident that the home can meet their needs and that they have an understanding about the running of the home when they move into to Chatterwood. Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 6 Robust medication procedures promote the well being of those living at the home. Where able to service users are supported to manage their own health needs. The management of the home promotes an environment where service users can exercise their choices regarding daily life. Service users are confident that the home will respond to any complaints in an effective manner. Service users are protected from the effects of abuse by a work force that has a good understanding about safeguarding adults. Service users live in pleasant surroundings; the home is kept clean and tidy sand there are a variety of communal areas for service users to utilise. Service users say that there are always enough staff on duty to have conversations with. Robust recruitment procedures and good training ensure that service users are cared and supported by a staff team that the relevant skills and qualifications. The management ethos at the home ensures that there is a seamless service for example the service was running efficiently when the manager was not on duty. A variety of methods are used to gain the views of service users and stakeholders about the running of the service; these views are used to influence the running of the home. What has improved since the last inspection? Increased management hours have been allocated to the manager. This has resulted in improvements been made with regard to paper work. Care plans and staff files are now organised in a way that makes the information more accessible and polices and procedures have been revised and updated as needed. The service after listening to service users opinions has made alterations to menu choices and has increased the variety of activities available for service users. The choice of bathing facilities for service users has been improved with the installation of an assisted bath and a shower unit. Skills for Care induction training has been introduced for new staff members. Following a food hygiene inspection in February 2007 improvements have been made to the kitchen environment and working practices in the kitchen. Fire safety checks are now clearly documented in line with Fire and Rescue Authority guidelines. Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 7 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. Chatterwood Nursing Home DS0000038996.V347442.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 Chatterwood Nursing Home DS0000038996.V347442.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, 2,3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good pre admission processes ensure that service users move into the home confident that the home will be able to meet their needs and with an understanding about the running of the home. The home does not offer intermediate care. EVIDENCE: The AQAA told us that all service users have an assessment of their needs prior to the decision being made as to whether the home is able to meet their needs. Prospective service users and their relatives are also encouraged to visit the home prior to moving in. As part of the inspection process three preadmission assessments of service users that had moved into the home in the last 12 months were looked at. These all contained details of the person’s needs and abilities regarding personal, health and social care. Additional information is provided by care managers and referring hospitals. Service user Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 10 surveys stated that they all have statements of terms and conditions of residency at the home detailing the service provided and had received sufficient information (statement of purpose and service users guide) about the service provided at the home to enable them to make a decision about the home. A statement of purpose is available in the entrance hall to view, as well as a copy of the most recent inspection report and service user’s and relative’s comments about the service. One service user who had moved in to the home in the past week said that although she did not visit the home her family visited. With their comments about the home and the information she received from the home she said she was able to make the decision that she would like to move into the home. Staff told us that they have sufficient information about a persons needs when they move into the home to care and support them in the manner they like and need. The home does not offer intermediate care. Chatterwood Nursing Home DS0000038996.V347442.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 &11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good care planning with the involvement of service users and their representatives ensure that service users receive the support and care needed to meet their personal and health care needs in the way they like. Service users are supported to manage their health care independently if able. Robust medication procedures protect the wellbeing of those living at the home. The home supports service users at the end of their life to have a ‘good death.’ EVIDENCE: The AQAA informed us that service users care plans had been updated since the last inspection. As part of the inspection process four service users care plans were looked at during the visit to the home. These evidence that much work has been done in improving the care plans. They now clearly detail the actions needed to meet the service users individual needs and their individual choices. They are reviewed on a monthly basis and updated when a service Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 12 users needs change. The format of the care plans has been improved since the last inspection making it significantly easier to access the required information. Discussion with service users and viewing care plans evidenced that service users and their representatives are involved in the care planning process; service users or their representatives sign the care plans confirming they agree with the plan of care. The AQAA states that the service has good relationships with the local GP’s, social workers, tissue viability nurses and members of the P.C.T. Service users documents detail contacts with health professionals evidencing the involvement of physiotherapists, chiropodists and social workers. The GP’s directly record into the service users documents; this ensures that changes of management of a person’s health care are implemented promptly. Service users told us in surveys that they believe their medical needs are always met, relative surveys told us the service always meet the needs of their relative living at the home. During our visit to the home service users said that the home contacts the GP promptly if they are feeling unwell, a visitor to the home also stated this comment. Staff spoke about the fact that GP’s respond promptly over any concerns they raise about service users. Where they are able to service users can manage their own health care needs. One service spoke about how he is accessing services for visual problems with minimal support from staff at the home. He appreciated being able to manage certain aspects of his health care home self. Relative comments about the care provided at the home include ‘My mother is well looked after,’ ‘ I am extremely satisfied with the care they provide,’ ‘meets the needs of its patients in a caring manner,’ and, ‘on occasions the doctor has been called the home have let me know and I have spoken to the staff or doctor.’ Staff comments include ‘Information is written clearly in care plan. If there is a change in management the manager will always come with a new care plan and let all members of staff know.’ And a GP has commented about the home stating they provide ‘very individualised care, look after the whole person’ All personal and health care takes place in the service users bedrooms or the bathrooms. Screening is available to protect the privacy of service users in shared rooms. No concerns have been raised to us about maintaining service users privacy and dignity and no evidence was seen during our visit to suggest that it is compromised. Medication policies and procedures were reviewed in August 2007 and the home has a copy of the Royal Pharmaceutical Guidelines for medication in care homes. The qualified nurses working at the home administer the medications. Prescriptions for all service users are kept on site and robust procedures are in place for the ordering, receiving and destroying of medications that ensures an audit trail for all medications received into and leaving the home is available. As part of case tracking we looked at four medication administration record Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 13 charts. A clear record is available for the amount and time of medications administered to service users along with the dose administered if the person is prescribed a variable dose such as one or two paracetamol of pain. Care plans contain details about each service users wishes in the event of death. Discussion with staff working at the home evidenced that dying is discussed with service users and their representatives when they are admitted to the home. Staff could give several examples of how the open discussion about death at the home has enabled service uses to discuss with their family members their wishes regarding funerals. Staff expressed that it is an important aspect of care to support an individual to have death and their funeral in the way they want. Chatterwood Nursing Home DS0000038996.V347442.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 benefit from the opportunity to take part in meaningful activities and being able to receive visitors when they wish. The ethos of the home supports service users to maintain control and choices over their daily lives. The wellbeing of service users is promoted by the provision of nutritional and varied meals. EVIDENCE: As part of the care planning process a resume of the service user’s life history is developed. This includes details about their life from childhood to the present moment detailing work, hobbies and family life. This enables staff at the home to know the person as an individual and be able to have meaningful discussions with the service user. The AQAA told us that in response to service user wishes improvements have been made in the menus and the variety of activities has increased along with introducing outings in the home’s minibus. The weeks planned activities are displayed on the notice board in the entrance hall. This indicates that activities such as reminiscence, music and craft Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 15 activities take place. A variety of books, board games and DVD’s are available for the service users to use if they wish. Service users surveys informed the Commission that there are usually activities that they can take part in but that activities offered are not always taken up. The statement of purpose and service users guide states that visitors are welcome at the home whenever service users wish. Service users told us that they can have visitors whenever they want. Service users told us they are able to make choices about their daily routines and activities. One service user said she ‘does her own thing’, another that he can do what he wants, ‘get up and go to bed when he wants, go outside in the homes grounds for a walk when he wants.’ During the visit to the home it was evident that service users were making their own choices regarding how to occupy them selves; whether being in the communal areas or in their bedrooms, joining in with activities, chatting with staff or other service users or relaxing in their bedrooms. Service users have choice about where to take their meals. There are two dining areas within the communal areas, or meals can be taken in the service users bedroom or in the lounge area. One lady who was eating her meal in the lounge area told us this was her choice. Service users said they enjoyed the meals provided and that they are given a choice. A menu plan is drawn up by the kitchen staff incorporating wishes from the service users and the known likes and dislikes regarding food of the service users. Chatterwood Nursing Home DS0000038996.V347442.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. Service users and their representatives are confident to voice concerns and complaints to the home knowing that they will be responded to promptly and with respect. A workforce that has a good understanding about safeguarding adults protects service users from the effects of abuse. EVIDENCE: The AQAA informed us that there is a relevant complaints procedure displayed in the entrance to the home and that all complaints are responded to immediately. In the last 12 months the home has responded to one complaint, a copy of which was sent to us. Records of this complaint and that actions taken to resolve the complaint were viewed in the complaints log book. Service users told us in surveys that they know who to speak to if they have any concerns and that they are aware of the complaint procedure. Discussion with service users during our visit to the home evidenced that service users do know who to voice complaints and concerns to and are confident that these will be responded to promptly. All seven of the relative surveys received by us commented that they know how to make a complaint about the service to the home. Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 17 The service told us that they provide good training about the protection of vulnerable adults and whistle blowing. The manager is booked to attend training about the mental capacity act in the New Year; information from this training will then be cascaded to the staff members at the home. Staff training records evidence that all staff have received training about the protection of vulnerable adults. In conversation staff were able to discuss the effects of abuse and the correct action to take should they suspect an act of abuse has occurred. Chatterwood Nursing Home DS0000038996.V347442.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 & 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 home that is homely in appearance and well maintained. Some lapses in following infection control procedures have the potential to put service users at risk from cross infection. EVIDENCE: The AQAA informed us that in the past twelve months the home has continued to redecorate bedrooms when there is a change of service user, a new shower room with chair, a new assisted bath, new moving and handling equipment and new bedroom furniture have been installed. Staff told us how the bathing equipment has given service users a greater choice in the bathing preferences. Prior to installing this equipment, due to moving and handling issues, many service users were unable to access the bath and had to have a bed bath, now they have a choice of bed bath, shower or full bath. In some of the bathrooms Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 19 there were bars of soap that were unnamed; this has a potential for cross infection to take place. Staff on duty promptly responded to this observation removing the tablets of soap from bathrooms and assurances were made that any further tablets of soap would be kept in named containers in service users bedrooms. A requirement has not been made about this issue as the service responded promptly and there is a good history of the service complying with regulations and requirements. A tour was made of the home viewing some of the bedrooms, kitchen, laundry and communal areas. On the day of the visit the home was seen to be clean and tidy, with no unpleasant odours. Comments from relatives surveys include ‘ the cleanliness is of a ‘very high standard, always clean and fresh smelling’. The bedrooms viewed looked homely and had been personalised by the service users and their families. Service users commented that they were glad that they could bring some of their ‘bits and pieces’ with them, which included photographs of their families and small items of furniture. The communal area is a very large room with separate areas that include dining areas, sitting areas and the conservatory and also has a storage area for the wheelchairs. The large gardens are landscaped, but much of the garden is inaccessible to the residents as the paths down to it are very steep. There is a large patio off the sitting room/conservatory and residents admire the gardens from there. The kitchen is small but has all the necessary equipment to cater for the residents. A food hygiene inspection carried out by the environmental health department was carried out in February 2007. The home has acted on requirements and recommendations made following that inspection improving procedures and the environment of the kitchen. The laundry is at the back of the home in a purpose built extension, with new equipment. Concern was noted in the last inspection about a vent leading from the pantry to the laundry area. This vent has now been removed and there is no communication between food storage areas and the laundry. The AQAA informed us that 80 of staff have had training about the control of infection and 100 of staff have had training about food hygiene. Staff training records confirmed that infection control and food hygiene training had been received as did discussions with staff members. Chatterwood Nursing Home DS0000038996.V347442.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, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff ensure that needs of the service users are met. Robust recruitment procedures protect service users and staff. Arrangements for induction and training ensure that staff are able to meet the needs of the residents. The home is working towards having the correct ratio of NVQ qualified staff. EVIDENCE: A staff rota in the staff office clearly details who is on duty at what time and in what capacity. There is always one trained nurse on duty and at many times two trained nurses during the day. Staff spoke to say that there are sufficient numbers of staff on duty at any one time to meet the needs of the service users living at the home. They said that there is always time to sit and have a chat with the service users; this is recognised as part of their care duties and is therefore built in to the staffing numbers. The AQAA informed us that all staff are recruited following a robust recruitment procedure that includes ensuring all checks are made regarding a person suitability of working in a care environment. Viewing a sample of staff Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 21 files evidenced that the recruitment procedure is followed. No staff commence employment until two satisfactory references and information from CRB and POVA has been obtained. These checks contribute to the protection of service user from abuse and the promotion of their welfare. The AQAA informed us that in the past twelve months service has introduced Skills for Care Common Induction training. This will ensure that new staff members have a good understanding about how to care and support a person. A recently employed staff member confirmed that she was following the induction programme. Staff told us that in the past six months they had had training about fire safety, infection control, first aid, moving and handling and food hygiene. Staff training is now recorded in a manner that easy to view and easy to assess when a staff member needs to renew their training. The AQAA told us that 33 staff at present have NVQ level 2 or above in care. The group manager said that the NVQ centre that staff were doing NVQ’s with had experienced problems recruiting assessors which had delayed several staff members achieving NVQ qualifications. The home is looking to find am alternative NVQ training centre for other staff members so they achieve the minimum standard of 50 of staff members with NVQ 2 in care. Comments from relative surveys regarding staff include ‘the staff are well trained, proactive and friendly. All the residents appear well looked after’ and ‘ I am very satisfied with the care my relative receives’. Chatterwood Nursing Home DS0000038996.V347442.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, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the skills of an experienced manager who ahs now been provided with the management hours to effectively run the home to improve outcomes for those living there. Service users and stakeholders views about the home are considered important in the development of the home. Service user’s financial interests are safeguarded by the home’s clear procedures for dealing with their money. Service users are protected by the regular supervision of staff. Good health and safety practices have been compromised by the risk of cross infection by unnamed tablets of soap left in bathrooms. EVIDENCE: Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 23 The registered manager is a trained nurse who is very experienced in providing nursing care in a residential setting. Mrs Joyce Gilfroy has worked at the home for more than fifteen years and has been the manager for over five years. She continues to attend training sessions to meet her nursing professional development requirements and has completed the Registered Managers Award. The AQAA states that ‘management hours’ for the manager have increased. During the course of the visit to the home the benefits from this increase in management hours was observed. Examples of this include the filing of information in service users documents and staff documents is more structured resulting in information being more accessible and policies and procedures have been reviewed and are now being reviewed on a regular basis. The manager was not available on the day of our visit to the home. A senior member of staff and the group manager for the organisation assisted the inspector. It was observed that the home was being run efficiently without the manager being on duty. This indicates that procedures are in place so that all staff know how the home is run and there is a seamless service whether the manager is in the building or not. Staff that spoke with us said that Mrs Gilfroy is very supportive and understanding and residents also said that they felt able to talk with her at any time. During the visit to the home it was apparent that the home had a relaxed and friendly atmosphere. The AQAA informed us about the ways in which the home obtains service users and stakeholders views about the running of the home. Service user meetings, surveys and one to one discussions with service users are some of the ways in which this information is obtained. Service users said they are able to discuss any issues with the manager and are confident that she will act on the comments. Changes in the menus and changes in the activity programme are examples of how service users wishes influence the running of the home. Other examples of how the home has improved its service for the benefit of service users is in the provision of new bathing facilities to allow service users to have a greater choice in bathing arrangements. Monthly visits to the home by one of the provider’s results in a report about the running of the home that takes onto account service users opinions contributes to quality monitoring at the home. The group manager performs a monthly audit of all the systems within the home. This includes amongst many cleaning schedules, risk assessments, staff files, the environment and catering issues. Any issues raised from this are discussed with the manager and action put in place to deal with issues. The AQAA stated that no money is held at the home for residents. Any costs incurred by the service users such as hairdressing, chiropody and the purchase Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 24 of newspapers were invoiced by the home to the person responsible for the residents finances. This was confirmed in conversations with staff and the group manager. Staff told us they have regular one to one supervision with the manager. Records are kept of the meetings. Staff meetings are also held; the AQAA states that the service plans to hold more frequent staff meetings and surveying of staff about the running of the home that will contribute to the quality auditing of the home. Staff said they can speak to the manager about personal or work issues at any time; in this way they feed into the management of the home even if they are unable to attend staff meetings. A requirement was made at the last inspection that the home must ensure that fire alarm tests are carried out weekly and the results documented. Records for checks on fire safety equipment and emergency lighting indicated that these checks are now being carried out and recorded. Records also showed that staff receive training in fire safety and attend unannounced fire drills. The home has used a professional body to risk assess the home for fire safety and have acted on any recommendations made following the risk assessment. All aspects of the environment are been risk assessed; documentary evidence is available that these risk assessments are reviewed on an annual basis or more frequently if required. Conversations with staff and training records evidence that staff receive regular training about health and safety topics. Health and safety notices are displayed throughout the home. Certificates evidence that equipment and services are maintained according to the manufacturers guidance protecting the safety of all at the home. Concerns about the use of tablets of soap and the resulting risk of cross infection are detailed in the section about the environment earlier in this report. Chatterwood Nursing Home DS0000038996.V347442.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 x 2 Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP28 Good Practice Recommendations Ways to increase the complement of staff trained to NVQ level 2 or above in care to meet the minimum requirement of 50 should be looked into. Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Chatterwood Nursing Home DS0000038996.V347442.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!