Inspection on 19/04/07 for Chegworth Nursing Home

This inspection was carried out on 19th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Chegworth Nursing Home 19/09/06

Chegworth Nursing Home 20/12/05

Chegworth Nursing Home 26/07/05

Chegworth Nursing Home 07/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Chegworth Nursing Home 23 Downs Side Sutton Cheam Surrey SM2 7EH Lead Inspector Alison Ford Key Unannounced Inspection 19th April 2007 11:00 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 Chegworth Nursing Home DS0000019083.V336294.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. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chegworth Nursing Home Address 23 Downs Side Sutton Cheam Surrey SM2 7EH 020 8642 9453 020 8642 8834 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) Bayswift Limited Mrs Puspavani Barkakaty Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Day care may be provided for a maximum of three people. Prior to any day care patients being admitted, the National Care Standards Commission must be informed in writing of the purpose of the placements, the facilities to be provided, together with the arrangements for staffing, needs assessments and care planning. A variation has been granted to allow one specified service user under the age of 65 to be accommodated subject to evidence of regular review of the situation and the service user`s assessed care needs. 19th September 2006 2. Date of last inspection Brief Description of the Service: Chegworth is a residential care home registered with The Commission for Social Care Inspection to provide personal and nursing care for up to thirtyseven older people. No other categories of registration apply. The home is a large, detached, domestic style house in a quiet road, providing accommodation in twenty-nine single bedrooms, of which three have en-suite facilities and four have W.C facilities; in addition there are four double bedrooms. There are two lounges separated by an office area and nursing station. There is no designated dining room; residents choose either to eat in the conservatory or at cantilever tables in the sitting room. The home is well maintained with a beautiful rear garden, which is enjoyed by residents in the warm weather. There is off street parking to the front for a limited number of cars and parking is permitted in the road outside the home. Fees at the time of this inspection range from £550- £850 per week. Any extra charges would be discussed prior to admission. Further information, a copy of the homes statement of purpose and the latest inspection report can be obtained from the home. The latter can also can also be obtained from The Commission for Social Care Inspection and via the internet. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2007/2008. In writing the report consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. The inspection visit was undertaken with help from the Registered Manager, her deputy and a senior nurse. All were helpful, knowledgeable and very receptive to the inspection process. A partial tour of the premises was undertaken; many of the thirty-six residents currently living in the home were spoken to, also two relatives that were visiting and several members of staff. Various records that the home is required to keep, as evidence of its commitment to the protection and health and safety of its residents, were seen and also a sample of care plans which identify the help and support that residents need and show how their assessed health care needs are met. Personnel files of new members staff were checked to ensure that they contained all of the necessary documentation that helps to ensure the protection of residents and staff training schedules were looked at to make sure that training is relevant to their needs. Menus and kitchen records were seen and the lunchtime meal was observed during the visit. No complaints or concerns have been received either by the home or by The Commission since the last inspection. What the service does well: This home provides a safe, clean and well-maintained environment for the residents who live there. The atmosphere is warm and friendly and residents find it a homely and a pleasant place to live. Aids and adaptations are in the home to help them and make their lives easier and a varied range of activities is offered to suit their capabilities and preferences. One resident has been able to have a section of the garden where she is able to grow her own plants and herbs. Several residents said how much they enjoyed living in the home and how lovely the staff were. Comments were received such as “ the people who look Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 6 after us are lovely” and “you couldn’t beat it here”. Others agreed that they “were all very happy” and “looked after very well”. Their relatives agreed that they were always made to feel welcome and that they never had any concerns about the care that is provided. All of the residents looked exceptionally well cared for on the day of the inspection; clothing had been colour – coordinated, ladies had been helped to put make-up on and the hairdresser visits regularly. It is considered that the home exceeds the minimum standards required in several areas, providing good facilities, which meet the healthcare needs of the residents and promoting a quality of life, which suits their capabilities and preferences. Staffing levels are sufficient to ensure that residents are not hurried and interaction between them and the carers is good. The continued employment of a clinical nurse teacher to work with care staff on a regular basis ensures that training is given a high priority and helps to contribute to the high standards of care within the home. A full and comprehensive assessment is undertaken by the matron or a senior nurse prior to the admission of any new residents so that they can be sure that their healthcare needs will be met. This then provides the basis for individual care planning. These care plans are subject to regular review to make sure that they are always up to date and that care is being delivered in a way which suits residents needs. There is evidence of involvement of the residents and their relatives. A doctor visits regularly and advice is gained from other healthcare professionals as required. Residents particularly enjoy the extensive range of activities that are offered to them and there are photographs around the home of them enjoying various events. They are also able to benefit from the skills of a physiotherapist and aromatherapist on a regular basis. The lunchtime meal was served during the inspection and those spoken with considered that the food was tasty and well presented and said that their relatives could join them at mealtimes if they wished to. Regular meetings are held with the chef and everyone is able to contribute their ideas and influence the range of dishes that are served. Barbeques are arranged when the weather is warm enough, in the garden. A robust complaints procedure is in place however none of the residents or relatives spoken to have ever felt the need to use it. They were confident that the management team would deal with any issues promptly as they occurred. The Registered Provider is often in the home and some residents recalled talking with him and his being able to provide equipment that they had asked for. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 7 The majority of the documentation required as evidence of the homes commitment to the health and safety of its residents and staff was in order and robust medication procedures are in place. What has improved since the last inspection? What they could do better: Prior to admission into the home residents and their families are given a service user guide. This outlines how the home is run and the services that are provided. In order that all of the information that might be required is available information must now be included about the range of fees that are payable and circumstances that might lead to these being increased. It was suggested that a copy of this information should also be left in resident’s bedrooms so that it could be referred to at a later date. Since the last inspection two members of staff had been recruited without some of the necessary checks being undertaken. This was as a result of a misunderstanding of the regulations and immediate steps were taken to rectify the situation. The management team were reminded of their responsibilities, Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 8 as failure to comply with theses in the future will influence the overall quality rating of the home. 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. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 9 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 Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 10 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): Standards 1,3,6 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. A full and comprehensive pre-admission assessment, undertaken by a senior member of the nursing staff, ensures that this home is able to meet the assessed healthcare needs of potential residents and that they will be happy living there. However, amendments must be made to the Service User Guide so that they have all of the information that they need to help them to make their choice. This home does not offer intermediate care Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans of residents admitted since the last inspection were seen. Two contained evidence of a comprehensive pre-admission assessment the other resident had been admitted as an emergency. A relative explained how this admission had been had been arranged in a way which had suited all of those that were involved. Care managers assessments were present in all of the files. The home uses a care planning system, “Standex” and the assessment information then forms the basis of subsequent care planning. There was evidence that relatives had also been involved in this process and had also contributed to risk assessments where these were required. Prior to admission, residents are given a Service User Guide, which is a book containing information about the home, and the services that are provided. This must now be amended, in line with recent regulations, so that it contains additional information about the range of fees that are charged and when and why increases may be necessary. A copy of the latest inspection report must also be included. So that residents or their families can refer to this book at a later date, if they need to, it is recommended that a copy should also be available in each resident’s bedroom. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10,11 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents in this home have an individualised plan of care, which is subject to regular review in order to, ensure that their assessed healthcare needs remain met and they can be confident that staff will always treat them with respect. Other healthcare professionals visit them and provide a range of treatments that are not offered in all other homes. Good medication policies and procedures are in place to ensure the total protection of residents. EVIDENCE: A sample of care plans was reviewed. Risk assessments were in place for manual handling, prevention of pressure sores and maintenance of safety. These plans are reviewed monthly in addition to resident’s annual reviews Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 13 There was evidence that relatives have been asked to contribute to these plans and are aware of their content including any activities that residents have chosen to participate in which may compromise their safety. . A range of pressure relieving equipment was seen in use throughout the home and care plans contained evidence of regular monitoring of skin integrity and body weight. Wound care is well managed with both documentary and photographic evidence available. Other members of the multidisciplinary healthcare team such as the tissue viability nurse, dentists, chiropodists and opticians make regular visits to the home and these are documented. Additional wheelchairs, a hoist and nursing beds have been purchased to make residents lives more comfortable. In addition to healthcare professionals that would be expected to visit, residents in this home benefit from a physiotherapist who attends twice a week. All residents are assessed on admission and those whose mobility might be improved are then seen on a regular basis and staff members would be shown how to help them at other times. Their progress is documented and reviewed regularly. An aroma therapist also visits weekly and all of the residents are able to enjoy a treatment approximately every six weeks. There are records kept of all of the therapeutic treatments that are used. Care staff were observed to be treating residents with respect and all of those spoken with agreed that staff were kind and caring. The majority of personal care is provided in resident’s own rooms although there is a still a frequently used toilet in the lounge area which can only be changed if the home is able to gain approval for proposed building works. Since the last inspection there is a new supplying pharmacist and medication procedures have been improved. Storage, recording and administration records were all in order. All medication is now supplied packaged individually in blister packs and, in addition, reminder notices are in place to alert staff to remember medication due that may be stored elsewhere. This is considered to be an additional safeguard, which will help to minimise the risk of any errors. The home will be participating in the End of Life initiative, which is a community-based project to provide the best quality care to people at the end of their lives. Meetings have already been held with the facilitators about setting this up. Chegworth Nursing Home DS0000019083.V336294.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): Standards 12,13,14,15 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. Residents in this home are able to participate in an extensive range of activities, which suit their needs. They are encouraged to maintain contacts with their families and friends and to exercise choices in their daily living in order to maintain their independence. A wholesome appealing diet is served which adds variety and interest to their lives. EVIDENCE: The extensive activities programme in the home adds interest to resident’s daily lives. Various photographs are displayed on the walls showing visiting entertainers and events and outings that have been arranged. The local library supplies books and religious representatives visit regularly. Two members of staff have now been on a course and provide chair-based exercise sessions twice a week and there are examples of craftwork throughout the home that residents have done while others enjoy art classes. Residents also participate in regular karaoke sessions in the home. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 15 They confirmed that they are supported to make choices within their daily lives and that their relatives and friends are always made welcome when they visit and offered tea. Residents were all complimentary about the food served in the home. The chef visits the residents in the morning to discuss the menu choices and alternative dishes are always available. Hot cooked supper dishes are served on most evenings and there is always homemade soup. The menu is displayed in the hall so that visitors can see what the residents will be having and they are able to join them if they wish. Another example of the staff in the home trying to improve the quality of care for their residents has been with the development of picture menus. Many residents have limited cognitive abilities and to help them make their meal choices digital photographs have been taken of the different meals and these have all been put into a book for them. Chegworth Nursing Home DS0000019083.V336294.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): Standards 16,18 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents in this home are confident that the complaints procedure in use within the home will ensure that any complaints that they might make will be treated promptly and with sensitivity. Policies and procedures are in place to ensure the protection and safety of residents. EVIDENCE: There is an appropriate and comprehensive complaints policy in use in the home and details are in the service users guide. No complaints have been received about the service since the last inspection. All of those that were spoken with agreed that should they have any concerns these would be dealt with swiftly by the matron and her staff. The Registered Provider is often in the home and relatives have previously commented that he was also very approachable should they have any problems. Regular training sessions take place to sure that staff are aware of how to recognise and respond to issues concerned with adult abuse. These would be dealt with according to locally agreed procedures. Those staff spoken with Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 17 were knowledgeable about the actions that should be taken if abuse was observed or suspected. Chegworth Nursing Home DS0000019083.V336294.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): Standards 19,26 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. This home provides a clean pleasant and well-maintained environment, which meets the needs of its residents in a homely and comfortable way. EVIDENCE: The home is situated in the suburbs of Cheam and there is a bus route nearby. Some parking is available in the front and there is a large rear garden. A shaft lift ensures that the entire home is accessible to its residents and adaptations have been made throughout the home, which are suited to the needs of older people. The overall ambience is homely and provides a pleasant place for people to live in although; some room sizes would not meet the requirements Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 19 of a newly built home. The Registered Provider is still hoping to extend the home in the future. There is a large lounge and a conservatory, which looks out onto the garden. A new gardener has recently been employed and the garden looked particularly attractive at this visit with a range of seating areas provided both for residents and for staff having their breaks. All areas are well maintained and a there is a continual programme of refurbishment and redecoration in place. Bedrooms are attractively colour coordinated and residents have been encouraged to personalise them with items of their own to make them feel more comfortable and homely. Automatic door closers are fitted to all the doors to ensure residents safety in the event of a fire. Since the last inspection an additional shower room has been completed. The home was, as always, clean and tidy and free from odour on the day of the inspection and, laundry facilities are sited away from areas used by residents. Bed linen and towels are sent out to a commercial laundry and personal items are washed in the home. Recognising the needs of the male staff in the home a new changing room has been provided for them and a new locked storage area for cleaning products and other COSHH items has also been installed. Chegworth Nursing Home DS0000019083.V336294.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): Standards 27,28,29,30 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. Residents can be sure that there will always be sufficient staff on duty to care for them and that generally there are recruitment policies in place to protect them. In order to maintain the wellbeing of residents, the management team of the home make every effort to ensure that staff are suitably trained for the work that they do. EVIDENCE: The home is always staffed according to previously agreed levels by a mixture of trained nurses and care staff working a combination of day and night shifts in order to improve the continuity of care given to residents. They are supported by a range of domestic staff who ensure that the home is always clean and tidy and safe for residents to live in. It is considered that training within the home exceeds the standards recommended by the National Minimum Standards. 97 of care staff are trained to at least NVQ level 2 standard and several of them are looking to progress to study at level 3. Two carers have already attained level 3 Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 21 qualifications and one has a level 4. Matron and her deputy and a senior nurse are studying for the Registered Managers Award at level 4. The home employs a very experienced clinical nurse teacher on a regular basis to support and work alongside care staff and trained nurses to maintain and improve their standards of care. A training schedule is in place and she is responsible for delivering a wide range of training within the home. A comprehensive twelve-week induction programme is in place for all new staff and there is regular supervision and appraisal. Staff also have every opportunity to attend training sessions from external providers. Residents can feel confident that staff are well trained for the work that they do and that they have the skills and knowledge to meet their needs. The files of two members of staff employed since the last inspection were seen. It would appear that, due to a misunderstanding of the regulations, appropriate clearance from the Criminal Records Bureau had not been obtained. Measures were put in place during the inspection visit to rectify this and an assurance was given that the staff members would not be working until satisfactory confirmation of the checks had been received. Failure to comply with recruitment legislation in the future will influence the overall quality rating of the home and discussions took place regarding the responsibilities of the management team in this matter. Chegworth Nursing Home DS0000019083.V336294.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): Standards 31,33,35,38 Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents can be confident that a competent person manages the home in their best interests and that their views will be taken into consideration. The management team of the home have policies and procedures in place to ensure the health and safety of residents and staff. EVIDENCE: The Registered Manager, a nurse, has been in post for some time and is very experienced in caring for this client group. A deputy and a senior nurse support her and residents are aware of the lines of accountability within the home. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 23 Staff meetings are held regularly so that all staff are aware of any new developments and are able to air their views. Residents / relatives meetings are held yearly so that they can contribute to the running of the home and relatives are invited to join the home for various activities throughout the year. A formal quality assurance form has now been developed and results of the outcomes were seen. The Registered Provider is frequently in the home and some residents said that they remembered speaking with him when he visited. A written report is available for some of these visits however this must be done monthly in line with Regulation 26. Failure to document these visits may be reflected in the overall quality ratings for the home in the future. The home does not take responsibility for the finances of any resident they all have a relative or representative to do this for them. All staff have undertaken training to ensure that their working practices are in accordance with current legislation and equipment has been maintained and checked appropriately. Policies and procedures are in place to maintain the health and safety of both staff and residents. Recently a fire risk assessment has been completed in line with new legislation and two new evacuation chairs have been purchased. Incidents and accidents are appropriately recorded, kitchen records are all well maintained and regular fire drills take place within the home. A recent visit from the environmental health department had not highlighted any concerns. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 45 Requirement Timescale for action 03/07/07 2 OP29 19(1) Schedule 2 3. OP33 26 The responsible person must ensure that the Statement of Purpose and Service User Guide are updated in line with current legislation so that potential residents have all of the information that they need to help them make their choices. The responsible person must 03/07/07 ensure that, in order that residents are protected from harm, no new member of staff begins working in the home without receipt of the appropriate clearance from The Criminal Records Bureau. The Registered Provider must 03/07/07 ensure that there is evidence available to show that visits have been made in accordance with Regulation 26 and that he is happy with the quality of care being provided in the home. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that a copy of the Service User Guide should be put into resident’s bedrooms for them to refer to. Chegworth Nursing Home DS0000019083.V336294.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Chegworth Nursing Home DS0000019083.V336294.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!