Inspection on 03/08/07 for Chaxhill Hall

This inspection was carried out on 3rd August 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 10/01/07

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 Unannounced Inspection 09:30 3 & 6 August 2007 rd 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.V336918.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.V336918.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.V336918.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. 10th January 2007 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 an adapted Victorian house and 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 people 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 person’s room and displayed on the notice board in the main entrance. The fees for this home are from £330 to £420 depending on the needs of the person. Additional charges that are not included in the fees are for hairdressing, chiropody and toiletries. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out the site visit, which took two days in August 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 both days of the inspection. A total of 27 standards were inspected. A number of people who use the service were spoken to and visitors to ascertain their views on the care and services provided. The comments received from people 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. Five requirements had not been complied with since the last two and in some cases three inspections. 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.V336918.R01.S.doc Version 5.2 Page 6 The home continues to improve their medication systems to reduce any risks to people who use the service. The Registered Manager has started to devise systems to be used as part of their quality assurance. 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.V336918.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.V336918.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, 2, 3, 5 & 6 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are not admitted to the home without first having an assessment of their needs completed. However the home needs to update the information they have available to people, to ensure they can make an informed choice about whether the home is right of them. EVIDENCE: A copy of the home’s Statement of Purpose and Service User’s Guide were examined because the Registered Manager was making changes at the last inspection. To meet the Care Home Regulations 2001 the home needs to add the following: • The experience and any qualifications of the Registered Provider • The organisational structure of the home • The procedure for emergency admissions • Other associated emergency procedures in the home. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 9 The Service User’s Guide requires additions to the homes terms and conditions to meet the Care Home Regulations 2001. These are: • The arrangements in place for charging and paying for any additional services • A statement as to whether it would be different for a person whose care in funded in part or whole by another source other than by the person themselves. The pre admission assessments of two recently admitted people were examined. One person was a planned admission and the other was an emergency admission. The Registered Manager has undertaken the assessment of the planned admission and had obtained information from Community and Adult Care Directorate (CACD) for the emergency admission. To ensure all information is obtained the home should complete all their pre admission format and date and sign each page. Discharge information from the local hospital was seen for both people, as the person who was admitted as an emergency had brought the information to the home that the hospital had given them. The home has devised a letter to send to new people who use the service detailing that their needs can be met, but has not sent it to people who are funded by CACD. This needs to be addressed. The home needs to amend their Statement of Purpose as it states they do not accept emergency admissions. Both people said their family had viewed the home on their behalf prior to them moving in and both were happy with the home. Intermediate care is not provided at this home. Chaxhill Hall DS0000016402.V336918.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who use this service are having their health and personal care needs met. However records pertaining to this are not always up to date or in place, which leaves care staff without clear instruction on how to meet the care needs of the people in the home. EVIDENCE: The care of three people who use the service was examined in detail. This involved, examining care records, speaking to the person and care staff. One person who was admitted in the last three months has not had care plans devised. Care plans from Community and Adult Care Directorate are in place but these have not been reviewed since admission. The home must address this as a matter of urgency. The two other people both had individual care plans in place, however one person was missing a care plan for communication needs and the other person needs more details adding as the care staff are undertaking more care than what is documented. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 11 Care staff spoken with about the three people who use the service demonstrated good knowledge of their care needs. Reviews were seen for two people’s care plans. The home’s Annual Quality Assurance Assessment (AQAA) said that the families, friends and advocates of people who use the service are invited to join in their reviews, however no evidence was seen of this in the three care records examined. Records are maintained of health professional visits and these include GP’s, Community nurses and Chiropodist. One person is waiting for a hearing test. The home’s AQAA states that dentists and opticians also visit the home. People spoken to confirmed they have visits from health professionals as one person had seen the Community nurse during the inspection. Moving and handling assessments were seen in all three peoples’ care records. The home uses the Waterlow assessment tool to help identify people who are at risk of pressure sores. However it was noticed that one person’s assessment did not identify the correct risk factor as the specialist area had not been scored, this can potentially place people at risk. The home must not use this tool if the care staff are not competent to use it. During the inspection the Registered Manager spoke to one of the Community nurses who agreed they would complete these assessment on people in the home until the home either trains its care staff or looks at using a different tool. Medication systems were examined. The home has continued to work hard at improving the systems used to ensure people who use the service are not put at risk. The home is working with the local dispensing GP practice in devising printed Medication Administration Records (MAR). This will stop the care staff from having to write them. The Registered Manager said they check the prescription against the Medication Administration Record to help reduce any errors. Records were seen of medication received into the home, administered and any that are returned to the pharmacy. All care staff that administer medication have undertaken training. A trolley is used for storage and to transport medication around the home. The Registered Manager or Deputy Manager audits the medication records monthly as part of their quality assurance. A care plan was seen for one person who self-medicates, this would benefit from having information for care staff about why this person needs this medication. A signature and initials list is in place for care staff that administer medication and the home has a drug reference book that would need to be updated in the next couple of months. The home did not have any one who is taking controlled medication at this inspection. People spoken with all felt the staff in the home respect their privacy and dignity. Two people had their own private telephones in their rooms. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 12 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices over their lives and maintain contact with family and friends. However the lack of a structured activities programme does not meet peoples recreational interests and needs. EVIDENCE: Since the last inspection the Registered Manager said the home has been working hard to devise an activities programme for people who use the service. However due to staffing issues the home has not provided any activities for a number of weeks. The majority of people spoken to said they were bored and all they had to do was watch the television or read newspapers. The Registered Manager said the home is looking to address this by recruiting an extra member of staff. One person said they would be unable to join in activities as they have difficulties with hearing people in a group. The hairdresser does visit the home weekly and one person said on a monthly basis a church service is held at the home. Another person said they are able to go outside for walks around the grounds. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 13 Visiting to the home is not restricted and visitors and people who use the service confirmed this. Visitors were seen during the inspection. One person said they attend a day centre each week. People who use the service said they are able to make choices about their daily lives. One person said they like to stay up and another said they like to have a ‘lie in’ each morning and the staff accommodate this. Information about advocacy is available in the home. People’s personal possessions were seen in their rooms and one person said they were able to bring in small items of furniture. Since the last inspection the home has a new full time cook. The home operates on a four-week rotational menu. The cook normally serves the food so she is able to find out from people who use the service their comments. She is aware of the likes and dislikes of people in the home. Records were seen of health and safety checks and of the food served to people, however more detail is needed in the food records, for examples when serving a buffet the staff would need to document what food was in the buffet. The home provides alternatives to meals, which is a vegetarian option. A mealtime was observed and people were seen enjoying the food provided. People spoken with said they enjoyed the food. Two new wipe boards have been provided in each dining to inform people what is on the menu for the day and special events will also be written on this board. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 14 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that assures people their views will be listened to and acted upon. However the home needs to update their adult protection procedures to ensure people who use the service will be put at risk of possible harm or abuse. EVIDENCE: The home has not received any complaints since the last inspection. However a complaint was sent to the Commission and Community and Adult Care Directorate (CACD). This was investigated by CACD and the Registered Manager felt there were areas that they could improve on following this. The complaints relates to the care of one person and general management of the home. The home displays copies of their complaints procedure and people who use the service said they would speak to the Registered Manager if they had any concerns. The Registered Manager has recently dealt with a concern about food portions in the evening and this has been addressed. All staff in the home except for any new staff have undertaken training in abuse. The home must ensure all staff receive this training. The home is yet to update their adult protection policy with the latest legislation and their Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 15 abuse policy does not contain detailed information about the types of abuse. The home has a whistle blowing and physical restraint policy. The home should consider sending staff on the ‘Alerters’ training provided by the local Council and the Registered Manager should consider attending the enhanced training. The home has not referred any staff to the POVA list. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 16 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is making slow progress in improving the environment for people who use the service and this could potentially place people at risk. EVIDENCE: A tour of parts of the environment took place with several rooms belonging to people who use the service inspected. At a number of previous inspections a requirement has been issued for the premises to remain in a good state of repair, however this keeps being repeated as at each visit because new maintenance issues are found and others not addressed. At the last inspection the home was asked to send a plan of refurbishment to the Commission but this has not been done. The Registered Manager said that they have started to redecorate rooms when they become vacant and two of these were seen and were much improved. Both people in them said how nice the rooms are. In one person’s room on Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 17 the first floor the window was open but restricted, consideration should be given to checking the gap of window restrictors to ensure people in the home are safe. The brown carpet upstairs has not been replaced and the Registered Manager said they want to decorate the corridors before the carpet is replaced, however the rucks are a risk to people as they could trip and fall. Maintenance issues outstanding: • Toilet by room 7 the toilet seat is very discoloured. • The brown carpet upstairs has rucks on it, which could potentially place service users at risk of falling over. • There were several areas both upstairs and downstairs that had brown stains on the ceiling. The Registered Manager said these are to be addressed as part of the redecoration programme. The leak in the ceiling on the upstairs floor has been repaired but redecoration of the corridor has not yet taken place. The programme for covering radiators remains on going, however the home needs to ensure people will not be put at risk by uncovered radiators. As part of their quality assurance a monitoring system must be put in place for the environment. The homes Annual Quality Assurance Assessment (AQAA) states “any maintenance requirements are dealt with immediately if it should prove to be a high risk otherwise it is recorded in the maintenance log”. The lift has been out of action since 20th July 2007 and was still waiting for parts during the inspection. People who use the service were happy with the cleanliness of the home, one of the rooms seen and the corridor by rooms 6 & 7 was odorous and this will need to be addressed. Staff were seen wearing protective clothing when needed. The laundry was inspected. The home maintains records of when bedding is changed in each person’s room. No laundry was seen being stored on the floor as it was at the last inspection. The home has a procedure in place for managing soiled linen and the disposal of incontinence pads. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 18 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 People who use the service experience adequate quality outcomes in this area. 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 people who use the service. However processes for staff training do not ensure staff have received induction training suitable for the tasks they are to perform. EVIDENCE: There have been no changes to the staffing levels at the home since the last inspection. The Registered Manager said they are confident the staffing numbers meet the needs of the people who use the service. However the home is looking to appoint another member of staff to help with the activities. People who use the service said the staff in the home are very friendly and helpful. Staff said they enjoy working at the home. The home has over the recommended 50 of staff trained in NVQ 2 or equivalent. The personnel files of two new members of staff were examined. All the required recruitment checks were in place except for one member of staff where a gap in their employment had not been explored. Criminal Records Bureau Disclosures (CRB) was seen for both members of staff and one had a Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 19 POVAfirst check in place. The home should consider keeping a copy of their checklist that they send to the agency that undertakes the CRB’s checks for them as part of the evidence they have seen the identity of the member of staff. Interview records are kept and a photograph of each person. The Registered Manager said that all staff are given a copy of the General Social Care Councils code of conduct. A new member of staff spoken with confirmed that the home had undertaken recruitment checks on them. The systems for training were examined. The home uses the Skills for Care common induction standards but are not registered with the scheme. The induction training for two new domestics was not recorded but the Registered Manager said had taken place. One of these has now transferred to provide personal care to people in the home and will therefore need an induction for this. A new member of care staff said other care staff are supervising them at the moment and when they first started at the home they ‘shadowed’ other members of care staff. The Registered Manager is a qualified trainer and provides training days for the staff. One recently took place and the topics covered were moving and handling, first aid, fire, infection control and food hygiene. Staff confirmed they have received training. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 20 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team have a supportive, open approach to running the home, which benefits the people who use the service, staff and relatives. However they need to ensure that all health and safety checks are taking place to reduce any risk to the people who use the service. EVIDENCE: There have not been any changes to the management of the home. Both the Registered Manager and Deputy Manager have NVQ 4 training. The Registered Manager is a qualified trainer and undertakes training days in the home for staff. The Commission is concerned about the number of requirements that have been repeated from the last two inspections and in some cases the last Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 21 three. The Registered Manager and Registered Provider must now address these as a matter of urgency. People who use the service and staff said the Registered Manager is approachable and they could go to her if they had any concerns. Staff also felt she was very supportive. The Registered Manager has started to devise their quality assurance systems and has put a number of monitoring systems in place. A person who uses the service has devised a questionnaire to be sent out to other people in the home. The home needs to look at ways of monitoring the environment. The home has safe systems in place to manage people’s monies. Consideration should be given to two members of staff signing the record sheet when money is put in or taken out for safety. The Registered Manager said that recently no formal staff supervision has taken place recently due to the staffing issues but is looking to restart them again very soon. Maintenance records were examined and it was found that the home has not undertaken any Legionella testing or obtained evidence that they do not need to do this. Fire equipment checks were not up to date on the record sheets but the Registered Manager said they had been undertaken. The fire risk assessment and evacuation procedure need to be reviewed in line with new legislation. Records for the checking of fire extinguishers had taken place, portable appliance testing was up to date and the electric certificate was dated 2003. The lift had been serviced but at the time of the inspection was not working. The home must inform the Commission of this and when it will be working again. Water temperatures checks take place. COSHH data sheets are available for any chemicals used in the home, however the storage of these need to improve to ensure they do not place people who use the service at risk. Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 22 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 1 2 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 2 Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 23 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. And send a copy to the Commission. This requirement has been repeated from the last two inspections. Timescale for action 01/10/07 2. OP2 3. OP3 5(1bc&bd) The registered person must update their Service Users Guide to include the information in relation to fees as described in this Regulation. This is to ensure that people who use the service have all the information about the service available to them. 14(1)(d) 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 two inspections. DS0000016402.V336918.R01.S.doc 14/11/07 06/08/07 Chaxhill Hall Version 5.2 Page 24 4. OP7 15 5. OP12 16(n) The registered person must 30/09/07 ensure that people who use the service have care plans devised for all identified needs, and these are kept updated to reflect their current needs. This is to ensure that the staff in the home has the information required to meet their needs. Consult and provide service 30/09/07 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 three inspections. The registered person must ensure the home’s adult protection policy is updated with the latest legislation. This requirement has been repeated from the last two inspections. 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 registered person shall ensure that all parts of the home are free from offensive odours. This will ensure that people live in a pleasant environment. The registered person must obtain a full employment history on all proposed staff with written explanation of any gaps in DS0000016402.V336918.R01.S.doc 6. OP18 13(6) 30/10/07 7. OP19 23 30/12/07 8. OP26 16(k) 30/09/07 9. OP29 19 30/09/07 Chaxhill Hall Version 5.2 Page 25 10. OP38 13(4a) employment to ensure people who use the service are not put at risk. The registered person must ensure that all chemicals used in the home are stored securely to prevent people who use the service from being at risk of injury. 06/08/07 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. 8. 9. 10. Refer to Standard OP3 OP8 OP9 OP18 OP19 OP19 OP30 OP30 OP38 OP38 Good Practice Recommendations The home should ensure that all sections of their pre admission assessment are completed, dated and signed by the person completing them. The home should not use the Waterlow risk assessment tool until all care staff that would use it have been trained in its use. The home should include in the person’s care plan for self –medication of a ‘prn’ medication why they need to take this. The staff in the home should consider attending the ‘Alerters’ training provided by the local Council and the Registered Manager the enhanced training. 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 are the correct width. The home should devise a training matrix. The home should register with the Skills for Care. 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.V336918.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Chaxhill Hall DS0000016402.V336918.R01.S.doc Version 5.2 Page 27 - 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!