Inspection on 10/01/07 for Chaxhill Hall

This inspection was carried out on 10th January 2007.

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

Chaxhill Hall 24/02/09

Chaxhill Hall 04/08/08

Chaxhill Hall 03/08/07

Chaxhill Hall 08/11/05

Chaxhill Hall 03/08/05

Chaxhill Hall 17/02/05

Chaxhill Hall 19/08/04

Chaxhill Hall 17/02/04

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

CARE HOMES FOR OLDER PEOPLE Chaxhill Hall Chaxhill Nr Westbury-on-Severn Glos GL14 1QR Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 08:00 10 & 11th January 2007 th 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 Chaxhill Hall DS0000016402.V326480.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. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chaxhill Hall Address Chaxhill Nr Westbury-on-Severn Glos GL14 1QR 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) 01452 760717 F/P 01452 760717 Mr Peter Albert Whitehouse Mrs Francesca Beverley Whitehouse Mrs Penelope Iris Jane Merry Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To add a total of 3 beds to be used for service users between the ages of 55yrs - 65yrs. 13th September 2006 Date of last inspection Brief Description of the Service: Chaxhill Hall Care Home is situated alongside the main A48 trunk road between Gloucester and Westbury upon Severn. It is a pleasantly adapted Victorian house offering comfortable rooms. The accommodation consists of thirty-two single and two double rooms, twenty-two of which have en suite facilities. Communal facilities consist of three large lounges, two on the ground floor and one on the first floor, and two dining rooms. The first floor is accessed by a shaft lift. There is a garden and patio area for residents to enjoy in the fine weather. Car parking is available at the front of the building. The home does not have a copy of their Statement of Purpose or Service Users Guide on display. Copies of the homes complaints procedure are in each service users room and displayed on the notice board in the main entrance. The fees for this home are from £320 to £420 depending on the needs of the service user. Additional charges that are not included in the fees are for hairdressing, chiropody and toiletries. The Registered Manager confirmed that the fee information has not changed since the last inspection. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors carried out the site visit, which took two days in January 2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager was available for one day of the inspection. A total of 25 standards were inspected. Several residents were spoken with to ascertain their views on the care and services provided. A number of surveys were left for service users, staff and visitors to the home. Of these, nearly all were complimentary about the home. The comments received from service users during the inspection all indicated they are very happy living at the home. The Registered Manager and care staff were spoken with throughout the inspection and were helpful and co-operative. Feed back on the inspection findings were given on completion and were received in a constructive and positive way by the Registered Manager. Since the last inspection the home has worked hard to meet the requirements issued. However, eight requirements had not been complied with. On this occasion the timescales have been extended as indicated in the requirements made. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale may lead the Commission for Social Care Inspection to consider enforcement action to secure compliance. What the service does well: What has improved since the last inspection? Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 6 The home has reviewed the format they use for care planning and their assessment of needs. This new format provides more information for staff about the care needs of the service users. Medication systems have improved with staff training and auditing. The home’s recruitment procedure has improved to ensure that appropriate checks are undertaken to reduce any risks to service users. The home has provided training for staff in the protection of vulnerable adults. 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. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 7 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 Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 8 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 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service Users Guide does not provide service users with sufficient information about the services the home offers. EVIDENCE: At the last inspection the home needed to make a number of amendments to their Statement of Purpose and Service Users Guide as listed below. To date the Registered Manager is working towards completing this. Organisational Structure of the home. The range of need that the home can meet based on the registration of the home. The arrangements made for consultation with service users about the operation of the care home. The arrangements made for service users to attend religious services of their choice. The number and size of rooms in the care home. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 9 The arrangements made for respecting the privacy and dignity of service users. The additions for the Services Users Guide are: Full complaints procedure. A copy of the homes terms and conditions. A copy of the homes contract. The home needs to change all references to the National Care Standards Commission to the Commission for Social Care Inspection. The Registered Manager said she would display both guides in the home once they are updated. It is recommended that the home review their terms and conditions in line with the latest Care Home Regulations that came into force in September 2006. The assessments of two recently admitted service users were examined. One of these was an emergency admission and the Deputy Manager confirmed that they received copies of their assessment completed by the Community and Adult Care Directorate (CACD) prior to them coming to the home. Both had assessments completed by the home. The second service user had visited the home prior to admission and had stayed for a meal. A requirement was made at the last inspection for the home to confirm in writing to new service users that having regard to the assessment the home is able to meet their needs. The Registered Manager has devised a letter but has not confirmed in writing to the two service users mentioned above that the home could meet their needs. Intermediate care is not provided at this home. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 10 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. Since the last inspection the home has made improvements with the care planning systems used, which now provides staff with more information to meet service users needs. The arrangements for the handling of medicines within this home have improved significantly since the last inspection. However the lack of attention to detail impacts on the home’s ability to protect the health and well-being of service users who take medicines. Some practice within the home currently affects the dignity of service users. EVIDENCE: The care of four service users was examined in detail. This includes reading their care records, speaking to service users where able and talking to staff. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 11 Following the last inspection the home has changed the format used for care planning and assessment of care needs. Two of these service users were new to the home. All had an assessment of need completed by the home. Consideration should be given to the home reviewing their assessment of need in line with Standard 3.3 of the National Minimum Standards for Older People, because the home’s assessment does not cover bathing or showering. Three service users had care plans completed by the home and the fourth service user who was receiving respite care was waiting for this to be completed. Reviews were seen of care plans but these were not always done monthly. Two service users require risk assessments as they are able to go out of the home independently and another service user requires a risk assessment for falls. Another risk assessment is also required for the service user who is able to make their own hot drinks in their room. One service user is receiving support from the Community nurses and the home was going to review their care plans due to a change in their condition. A service user was being nursed on a mattress on the floor for safety reasons, however this puts both the staff and service user at risk due to moving and handling procedures. During the inspection the Community nurses were visiting this service user and were going to order a suitable bed. The home needs to consider putting moving and handling assessments in place for all service users and a falls risk assessment. Service users spoken with said that they have access to health professionals to include their GP, Community nurses and chiropodist. The home also documents visits on a records sheet for each service user. The way medicines are handled in this service has changed significantly and many improvements made. There is a new medication policy and procedures available and staff sign that they have read this. Staff who administer medicines have received training about the safe handling of medicines. Audits are performed regularly to check that service users are having their medicines correctly and that the records are up to date. Any issues found are noted and staff advised about this. Information about medicines were looked at for two service users who have recently come to the home. There was nothing in the care plans about how checks were made about the medicines each person should be taking. Medicine charts were prepared from the labels on the containers of medicines brought into the home and for two medicines for one service user; there was a form from the hospital. Checks should be made with the GP or other health professional to confirm what are the correct medicines. Records in other care plans showed when health professionals attended residents and this included reviews of medicines. Medicine charts are written out in the home on a specially designed form. The records on these charts had improved since the last visit and this inspection Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 12 showed the records were generally accurate. Home staff make their own regular checks to monitor that medicines are given and recorded correctly. There were some exceptions as listed below so there is still progress to make to improve records about medicines: • Inspection of a sample of charts showed that the information is generally correct. It is good practice for a second staff member to check that all the information is accurate and sign as such each time the chart is rewritten or additions are made. For example, the strength of a tablet was missing on one chart. For a few other medicines the information on the chart was not exactly the same as that on the medicine label. ‘One or two tablets’ or ‘as required’, whilst on the label, was not copied on to the medicine chart. For other recent changes in dose the doctor had signed the chart or provided written information with the change and this was on file for staff to refer to. Several medicines are prescribed for various service users to be used ‘as required’ but more information is needed to describe what ‘as required’ means for this person. Records for two service users were looked at and this information was not recorded. A suggested way is to write a protocol in a standard format for any medicine prescribed ‘as required’ and keep with the medicine chart so that all staff can refer to this and know how the medicine is used for this person. One service user started a course of eight tablets daily for two weeks starting on 30/11/06 as prescribed from the hospital. The tablets were still being given but there was nothing written down from the hospital doctor about continuing the treatment. Staff said that there had been a telephone call about this and another blood test is due soon. More complicated treatments such as this need to be properly recorded. There were still occasional gaps on the administration records with nothing written in so it was not possible to tell if a dose was missed or staff had forgotten to sign the record. For one service user since 11 December 2006 there were eleven gaps for a 5pm dose. An audit count of remaining tablets was four short compared to records, which may indicate some doses had been given. Audit counts of fifteen medicines in stock were checked with records. Nine counts were correct but six showed discrepancies so sometimes service users may not have received their medicines correctly or the records are not accurate. On some records where a dose of one or two tablets is prescribed the dose given is not entered on the chart. A painkiller containing paracetamol for another service user is labelled to give ‘4 to 8 daily’. The MAR chart is marked for doses of 1 or 2 tablets at 8am, 12 noon, 6pm and 9pm. The interval between each dose must be at least four hours. The dose given is not always noted. Staff thought the teatime dose would in fact be given at 5pm in which case the records should say this. Audits were not possible on some medicines, as the date of opening is not written on the container label. DS0000016402.V326480.R01.S.doc Version 5.2 Page 13 • • • • • • • Chaxhill Hall • Some tablets for one service user were marked as not available from 2/1/07 – 9/1/07. This could have affected the health and well being of this person. A small number of service users look after some of their own medicines. A full risk assessment was seen for one service user but for another service user who looked after just two medicines there was no risk assessment and this service user had lost their key to keep the medicines safely locked away. A service user who had recently come to the home wished to look after his medicines and the home were in the process of arranging this. Each time medicines are given to the service user to look after this should be noted on the medicine chart as way to help check the medicines are used correctly. Observations were made of staff giving service users their medicines at lunchtime. Accepted safe practices are followed of taking medicines directly from the labelled packets and making direct reference to the medicine charts whilst close to the resident. Medicines are held safely in a proper locked medicine trolley. The day shift staff now administer the breakfast medicines, which is a safer practice. New storage arrangements have been made and medicines are now all stored safely, including those products needing fridge storage. Medicines used externally should be kept on separate lower shelves from any medicines that are swallowed. There are safe arrangements for dealing with any controlled medicines. Eye drop bottles had a date when opened on the label. In one bedroom tubs of cream were kept on top of the cupboard in the bathroom. One tub was new and but the other pot was opened 22 October 2006 so should be replaced. There is good practice guidance or manufacturers’ information about the shelf life of medicines when opened to use. There is a now an up to date medicine reference book for staff to refer to. Service users spoken with said the staff in the home respect their privacy and dignity. One service user said they have a lock on their door. The chiropodist and hairdresser were both visiting the home during the inspection and using the upstairs lounge. Service users were having their hair done and the chiropodist was cutting service users nails in the same room with service users sat waiting. After they had finished the hairdresser had left hair all over the floor and there would also be toenail clippings. Service users use this lounge and a relative was also having a meeting with an outside professional. Whilst the home has limited space, it must consider service users dignity. From discussions with the Deputy Manager a bathroom has been made available to Community nurses and she suggested the chiropodist could use this as it is easier to keep clean and service users will be seen in private. The home is to review the hairdressing arrangements. Chaxhill Hall DS0000016402.V326480.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 adequate. This judgement has been made using available evidence including a visit to this service. Links with the community are maintained where possible. Whilst recreational activities are provided, service users do not have a structured and co-ordinated programme. The meals in the home are good offering variety and some choice and catering for special dietary needs. EVIDENCE: It was identified at the last inspection that the home does not have a structured activities programme in place. The Registered Manager said that this is something the Deputy Manager is going to be working on. An activities poster was seen advertising events for November 2006 and activities provided at Christmas. The Registered Manager has set up a file to store posters and is looking to get staff to feedback on activities. One service user said that she read in the homes brochure that craft classes take place but she has been at Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 15 the home for over a year and this has not happened. One service user is able to play a musical instrument and is looking to entertain the other service users. One service user said they are able to undertake their own activities. The hairdresser was visiting the home during one of the days of the inspection. No activities were taking place during both days of the inspection. Three service users are able to go out alone and another said their family takes them out. A visitor and service users confirmed that visiting to the home is not restricted. One service user was going to a day centre on the first day of the inspection. Service users spoken with and three service users surveys returned following the inspection all said they could choose how they spend their time each day. Service users rooms seen during the inspection were personalised and had a number of their personal belongings displayed. Information regarding advocacy is available in the home. No changes have been made to the menus or the process for devising menus since the last inspection. Menus are displayed in one of the dining rooms but the home should consider if the format is suitable for the needs of all service users as the wording is quite small. Health and safety records were not checked at this inspection as they up to date at the last inspection. Lunchtime was observed on both days and was found to be a sociable event with the majority of service users eating in the dining rooms. As the home has two dining rooms a rota system is in place for which room is served first. A choice is offered with two main courses and if a service user requires an alternative for example vegetarian. The cook serves the food with help from the staff. Drinks are offered with their meal. The majority of comments received about the food were very good, however a comment received from a service user was that the portion sizes could be on the small side. Drinks were being offered to service users throughout the day. One service user felt the food ‘is ok at lunchtime but the evening meals are not as good and they have a limited choice as the care staff have to prepare them’. Chaxhill Hall DS0000016402.V326480.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place, but to date the Registered Manager has not received any. Since the last inspection the home has improved their arrangements for protecting service users from possible abuse. EVIDENCE: The home has not received any complaints since the last inspection. Complaints procedures are displayed around the home. Service users and a visitor spoken with all said they could approach the Registered Manager if they had any concerns. Service users and visitors surveys returned all said they were aware of the homes complaints procedure and whom they would speak to. Since the last inspection all staff have undertaken adult protection training and three staff surveys returned following the inspection all said they know the procedure to follow. The Registered Manager has not updated the homes policy with the latest legislation but plans to complete this shortly. At the last inspection staff had signed to say they have read the homes whistle blowing policy. No staff have been referred to the POVA list. Chaxhill Hall DS0000016402.V326480.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to the environment are needed to make it a pleasing and pleasant place for service users to live. EVIDENCE: A tour of the environment took place with a number of service users rooms inspected. A number of maintenance issues found at the last inspection remain outstanding, these are: • No flooring in the room next to the kitchen, which stores the boiler and staff lockers room. • Toilet by room 7 had wallpaper peeling off the walls and the toilet seat was also discoloured. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 18 The brown carpet upstairs has rucks on it, which could potentially place service users at risk of falling over. The Registered Manager said that this is due to be replaced. • In one of the dining rooms there is no window restrictor. As the home has service users with mental health conditions this must be addressed as the home is next to a busy main road. • There were several areas both upstairs and downstairs that had brown stains on the ceiling. The Registered Manager said these are to be addressed. The décor in places is looking tired, whilst this does not impact on the well being of service users it does not make for a pleasing or pleasant environment to live in. On the first floor the home has a leak in the ceiling they have appointed contractors to deal with this, but they are waiting for the weather to improve. The Registered Manager said the Registered Provider has plans in place to redecorate the home. A copy of these plans was not in the home but will be forwarded to the Commission. One empty room is waiting to be redecorated prior to a new service user moving in. Since the last inspection the Registered Managers office has been redecorated and is much improved creating a better impression of the home. The Registered Manager said that there is a programme in place to cover all radiators. Consideration should also be given to checking the gaps on the window restrictors to make sure they are the correct width. Service users spoken with were all happy with the cleanliness of the home and no other issues were identified except an odour in one of the service users rooms. The Registered Manager is aware of this and is considering replacing the flooring. Staff were seen wearing protective clothing when needed. The laundry was inspected and found to be in a satisfactory condition except that staff are putting soiled laundry on the floor whilst waiting to be put in to the washing machine. This is an infection control risk and soiled linen should be placed in a suitable container. Consideration should be given to the home purchasing red alginate linen bags that can be put into the washing machine as they dissolve reducing the risks to staff. • Chaxhill Hall DS0000016402.V326480.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, 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 home is confident that the numbers of staff on duty meet the needs of the service users and the processes for staff training are improving to ensure staff receives the appropriate training and supervision. The changes made to the homes vetting and recruitment practices will ensure the appropriate checks will be carried out to reduce any risks to service users. EVIDENCE: The Registered Manager has reviewed the staffing arrangements in the home so that four care staff are on duty for the morning shift and afternoon shift. The home has two waking night staff. The Registered Manager or Deputy Manager when in charge of the home are extra to the staffing numbers. The home has domestic cover, laundry and a cook seven days a week. Maintenance assistance is obtained when required. Five visitors surveys returned all said they felt sufficient staff were on duty and two said the staff are very friendly and helpful. Service users spoken with all said the staff were friendly and helpful and the three service users surveys returned all said the staff always treat them well. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 20 Three staff surveys returned made comments to include ‘it is a friendly and homely place to work’. However one comment was that communication could be improved. The home has one member of staff with NVQ 3 and two staff due to complete in April 2006. Six members of care staff are due to complete NVQ 2 very soon and two have just started this training. The home has not had any new staff since the last inspection. However the Registered Manager has made changes to the application form to ensure the home obtains all the required pre employment checks. Since the last inspection the Registered Manager has devised a form to record induction training. The home uses the common induction standards for social care for their programme. Training provided for staff since the last inspection includes abuse, and an ASET course in health and safety. This course covers fire and moving and handling training. The Registered Manager is due to devise a training matrix. Chaxhill Hall DS0000016402.V326480.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, 32, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has a supportive, open approach to running the home, which benefits the service users, staff and relatives. However there are areas that still need improvement to meet the standards. The views of service users and visitors are not always sought when monitoring the standards at the home. Safe systems are in place to manage service users monies. The home has systems in place to ensure the staff are supervised. The home does not fully ensure that the health and welfare of service users, staff and visitors to the home is promoted and protected. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 22 EVIDENCE: Since the last inspection there have not been any changes to the management of the home. Both the Registered Manager and Deputy Manager have the NVQ 4. The Registered Manager is experienced in managing a care home for older people. Since the last inspection the home has made good progress in meeting the requirements, however several areas still need to be addressed. Service users, staff and a visitor to the home all confirmed that they could approach the Registered Manager to discuss any concerns they might have. Service users and a visitor were observed going into the Registered Manager’s office at different times during the inspection. The Registered Manager is yet to establish and maintain a system for reviewing the quality of care given. Plans are in place for service users meeting in the next few weeks and one for staff. Audits are in place for medication and accident records. Handovers take place at every shift. The Registered Manager is going to devise a satisfaction questionnaire for service users and visitors to the home. Regulation 26 visits are taking place monthly but the reports are not being sent to the Commission monthly. These must be sent monthly to the Commission. The homes policies and procedures need to be reviewed to ensure they are up to date with the latest legislation. The home manages a number of service users monies. The appropriate records and receipts are kept. There is no policy in place and consideration should be given to devising one. The Registered Manager has undertaken staff supervision sessions as records were seen of some sessions with staff. However no sessions have taken place since the last inspection. The Registered Manager said sessions have taken place but records have not been maintained. Maintenance records were examined at the last inspection and several checks had not been completed, these include central heating and Portable Appliance Testing. The Registered Manager said the central heating was due to be checked the week of the inspection and the home is waiting for the electrician. Water temperatures are being checked on a monthly basis and the home still needs to obtain written verification about Legionnella testing and if the home needs to be undertaking this testing. The home has a health and safety company visit and their certificate was seen displayed on the wall. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 23 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 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 3 2 X 2 2 X 2 Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 6 Requirement The registered person must add the additions to their statement of Purpose and Service Users Guide as described in this standard. This requirement has been repeated from the last inspection. The registered person must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. This requirement has been repeated from the last inspection. The registered person must ensure that where required service users have risk assessments in place that are kept under review. This requirement has been repeated from the last inspection. Make suitable arrangements for the recording, handling and safe DS0000016402.V326480.R01.S.doc Timescale for action 01/03/07 2. OP3 14(1)(d) 11/01/07 3. OP7 13(4)(c) 28/02/07 4. OP9 13(2) 28/02/07 Chaxhill Hall Version 5.2 Page 25 5. OP12 16(n) administration of medicines. (This refers to making sure medicines are always administered as prescribed and making complete, accurate records of medicines administered; checking medicines for newly admitted residents with a health professional; keeping written protocols for the use of any medicine prescribed ‘as required’; having a risk assessment for each person who looks after any of their own medicines with a record each time a supply is given to them to look after.) Consult and provide service 28/02/07 users a programme of activities having regard to their needs in relation to recreation, fitness and training. This requirement has been repeated from the last two inspections. The registered person must ensure the homes adult protection policy is update with the latest legislation. This requirement has been repeated from the last inspection. The Registered person must ensure that the premises are of sound construction, kept in a good state of repair internally and externally and kept reasonably decorated. Refer to this standard for details on issues identified. This requirement has been repeated from the last three inspections. The provider shall visit the home DS0000016402.V326480.R01.S.doc 6. OP18 13(6) 01/03/07 7. OP19 23 01/07/07 8. OP33 26 11/01/07 Page 26 Chaxhill Hall Version 5.2 at least monthly unannounced, interview service users, their representatives and staff, inspect the premises and prepare and submit a written report to CSCI. This requirement has been repeated from the last two inspections. 9. OP33 24 The registered person shall establish and maintain a system for reviewing the quality of care at regular intervals. This requirement has been repeated from the last inspection. 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP2 OP7 OP8 OP9 OP15 OP19 OP19 Good Practice Recommendations The home should review their terms and conditions inline with the latest Care Home Regulations that came into force in September 2006. The home should review service users care plans monthly unless their condition dictates otherwise. The home should undertake moving and handling assessments on all service users. A second authorised staff member to check and sign as correct any handwritten information about medicines and doses on the medicine charts The home should devise their menus in other formats so all service users are able to read them. The home should have a programme of redecoration in place to improve the environment for service users. The home should check window restrictors to ensure they DS0000016402.V326480.R01.S.doc Version 5.2 Page 27 Chaxhill Hall are the correct width. 8. 9. 10. 11. OP26 OP30 OP38 OP38 The home should consider purchasing red alginate bags for soiled linen as the dissolve in the wash. The home should devise a training matrix. The home should ensure that all the required maintenance and checks by contractors are up to date. The home should obtain written verification that they do not have to undertake Legionella testing. Chaxhill Hall DS0000016402.V326480.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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