Inspection on 26/10/06 for Cheneys

This inspection was carried out on 26th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cheneys 19/08/08

Cheneys 03/10/07

Cheneys 19/12/05

Cheneys 24/05/05

Cheneys 26/10/04

Cheneys 24/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cheneys Links Road Seaford East Sussex BN25 4HY Lead Inspector Rebecca Shewan Key Unannounced Inspection 26th October 2006 09:30 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 Cheneys DS0000028541.V308543.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. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cheneys Address Links Road Seaford East Sussex BN25 4HY 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) 01323 893373 Sussex Housing and Care Vacant Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fiftythree (53). Service users must be older people aged sixty-five (65) years or over on admission. Up to a maximum of thirty-three (33) service users may be in receipt of nursing care. 19th December 2005 Date of last inspection Brief Description of the Service: Cheneys is situated in a quiet residential area of Seaford a short walk from the seafront and approximately half a mile from the town centre with its access to bus and rail routes. The home is registered to accommodate up to 54 older people, 33 of whom may be in receipt of nursing care. The registered owners are Sussex Housing and Care. The home is part purpose built and part converted with accommodation over two floors. The home comprises of 48 single bedrooms (26 of which have ensuite facilities) and 3 double bedrooms (all 3 of which have en-suite facilities). There are additional toilet and bathroom facilities throughout the home. Rooms are located over two floors, accessible by two passenger shaft lifts. The home has a number of specialist equipment in use such as mobility aids, specialist nursing beds and bath and moving/handling hoists. There are extensive attractive gardens to the rear of the property that are accessible to residents. There are car-parking facilities to the front of the premises. Potential new service users can obtain information relating to the home via the internet, CSCI Inspection Reports, Care Managers, Placing Authorities, by word of mouth and by contacting the home direct. The range of fees charged (at the time of this report) are £335 - £640 per week, with additional charges made for newspapers, hairdressing, toiletries and chiropody. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the 26th October and the afternoon of the 31st October 2006. Incident reports, Monthly unannounced monitoring visit reports, previous inspection reports and the home’s Pre-Inspection Questionnaire, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took eight and a quarter hours. A tour of the whole home was undertaken and the Manager, the Deputy Manager, five staff and five service users (known as Residents), were spoken with. Records such as care plans, policies and procedures, maintenance records and medication records were also viewed. Service User Surveys were distributed of which twenty on were returned (NB: six were completed on the residents behalf by a Friend of Cheneys representative). Comments received included: The home were requested to complete a Pre-Inspection Questionnaire, which was returned in a timely manner. Forty seven residents were accommodated at the home at the time of the inspection. What the service does well: The home ensures that thorough pre- admission assessments are carried out on all new and potential residents with only those who needs can be met, being admitted to the home. The health needs of residents are well met with evidence of good multi disciplinary working taking place. Staff provide personal support to residents in such a way that promotes and protects resident’s privacy and dignity. Activities are arranged according to resident choice. Mealtimes are unhurried and all meals are home cooked with an alternative option being available for each mealtime. There is an efficient complaints procedure in place and the homes processes and staff training should protect residents in the event of an allegation of abuse. The location and layout of the home are suitable for its stated purpose. All areas of the home are accessible to residents. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 6 The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. The management and administration of the home is good, with evidence of consideration being given to resident’s and/or relatives opinion. What has improved since the last inspection? What they could do better: IN the interests of the health, safety and welfare of residents and staff, the home must ensure that urgent action is taken to ensure that all handwritten entries onto MAR sheets must be signed by two staff and an explanation for the handwritten entry entered onto the back of the MAR sheet, that all medications administered, which are creams/lotions/ointments, must be signed for by the person who has administered the treatment, that air fresheners are removed from all bathroom and toilet areas and are stored in accordance with the C.O.S.H.H Regulations and that liquid alcohol hand sanitizer dispensers must be deemed static and tamper proof or removed from all bathroom and toilet areas. The home must ensure that care plans are drawn up in consultation with residents or their representatives as appropriate and that where this is not practical, care plans reflect this, in order to ensure that residents are involved in the development of the records maintained, which detail their needs and limitations. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 7 Staffing numbers must be monitored and altered according to the level of need of all service users in order to ensure that all residents needs are being met. The home are also advised that entries onto residents daily care records are reflective of the residents care plan and in accordance with the NMC guidance on Documentation and Record Keeping. Staff who make entries onto residents daily care records, should record the date, time and their job designation on each entry made, in accordance with the NMC guidance on Documentation and Record Keeping. Residents fluid balance charts are to be maintained appropriately ensuring that all fluids taken and omitted by the resident are clearly recorded, in order to ensure that residents fluid balance is appropriately maintained. That 50 of staff are trained to NVQ level 2 by the end of 2005. (This is outstanding from the previous inspection). 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. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has good processes for assessing potential new resident’s with services being offered to only those resident’s whose needs can be met. EVIDENCE: The home’s Manager and/or Deputy Manager carry out pre- admission assessments. The Manager reported that on occasions newly employed nurses of the home also attend pre- admission assessments in order to gain an overview of the admission process. Records inspected showed that preadmission assessments are carried out on all new and potential residents. It was noted that the documentation allows the assessor to gain a good overview of individuals medical, social and personal care needs. The home also obtains a copy of a care management assessment from a placing authority where this exists. Any issues, which are highlighted within this assessment, are addressed by the home and documented records are maintained of all correspondence with the placing authority. Residents confirmed that they had been involved in the assessment process and had felt included in their admission to the home. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 10 Intermediate care is not offered by this home. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area is adequate. This judgement has been made using the available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by the home. However improvements are required to ensure that care plans are devised with the residents involvement, that daily care records require improving to be care plan specific and that medication records are maintained appropriately in order to provide a clear audit trail of all medications prescribed. EVIDENCE: The home has made improvements since the inspection of December 2005 to ensure that care plans are updated to reflect the changing needs of service users. Four residents individual care plans were viewed and it was noted that these were detailed in content and covered all aspects of resident’s needs. Suitable risk assessments were in place for the complications associated with reduced mobility, trip/falls hazards and associated risks. However, from the care plans sampled it was evidenced that neither residents/relatives/representatives signatures were recorded. Residents spoken with during the inspection commented ‘what is a care plan?’ and ‘should I know what my care plan is?’ Of the service user surveys received one respondent commented that ‘there is a lack of communication about care’. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 12 Daily care records were also viewed and it was noted that many entries were signed but not dated, timed or the person’s designation recorded. Entries were also noted as being recorded as ‘is fine today’, ‘fine’, ‘usual care given’ and ‘is ok today’. Fluid balance charts were also viewed and it was evidenced that these documents are not well maintained, with residents charts having been completed for some hours of the day, with large time gaps noted where no entry had been made for fluids inputted or outputted by the resident. Therefore requirements and recommendations have been made. From the records sampled and from discussions with staff it was evidenced that the health needs of residents are met by a multi disciplinary approach, on a required basis. The Manager said that residents have a choice of GP from one of the local surgeries. Resident’s are encouraged to attend the GP surgery were able and home visits are conducted when necessary. Referrals to the Occupational Therapist, Physiotherapist and Audiologist are made via the GP or the hospital. The home has access to pressure relieving equipment as well as medical aids and adaptations. The home has good procedures in place for the monitoring and recording of all drugs entering and leaving the home. The controlled drug register was viewed and this was found to be maintained in an appropriate manner. The store for medication was viewed and was found to be maintained in a clean and orderly manner. The medication fridge records were also viewed and it was evidenced that fridge temperatures had been maintained on a daily basis. However, the medication administration record (MAR) sheets were viewed and it was evidenced that some improvements are required, to address the manner in which staff record medications either administered or non- administered. It was evidenced that where medications such as creams/lotion/ointments have been prescribed, entries onto MAR sheets are not completed. Therefore giving the impression that these are not administered. Some handwritten entries were also noted and it was evidenced some, but not all, of these were unsigned or signed by one staff member only, undated and that no explanation had been given on the back of the MAR sheet for the reason for the handwritten entry. Therefore requirements have been made. Staff were observed providing personal support to service users in such a way that promoted and protected residents privacy and dignity. Of the twenty one service user surveys received four stated that they always received the care and support that they needed, fifteen responded that they usually received the care and support that they needed, one responded sometimes and one did not respond. Comments received include: ‘I was suffering from bed sores and Cheneys were marvellous and treated the sores and eventually got rid of them’, ‘many times my helpline is missing and I cannot get help’, ‘of course the nursing patients get priority and the residents come a poor second’, ‘I do not need at the moment any special care or support’ and ‘the majority of staff are very helpful and caring’. Residents spoken with stated that ‘staff are thoughtful and considerate’, I never have to wait for long if I call for help’ and Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 13 ‘staff are lovely, kind and caring tough sometimes it feels like there are not enough of them and we have to wait a while for assistance’. Cheneys DS0000028541.V308543.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides good social, cultural and recreational facilities, including a specialist diets to residents, with resident’s choice and wishes being respected. EVIDENCE: The variety of activities offered by the home are planned in advance and after consultation with residents. Residents said that they enjoyed many of the home’s activities and that the home staff were flexible in allowing residents to choose the level of activities attended. A published list of activities is made available to residents, with residents being informed of special events being held in the home. Activities include bingo, quizzes, motivation and music and gentle exercises. Residents spoken with during the inspection said that ‘ we enjoy the activities but don’t go to all of them, which is our choosing’, ‘I love the bingo!’ and activities are good, I enjoyed the new one this morning and hope they come back’. Of the twenty one service user surveys received five responded always, four responded usually and eight responded sometimes to the question that asks ‘are there activities arranged by the home that you can take part in?’ Four did not respond but stated that ‘this is because I choose not to attend’. Comments received include ‘I think activities are minimal and some days are very boring’, ‘Not enough exercise, I like the music and exercise but it doesn’t happen often enough’ and ‘I enjoyed a recent bus trip outing’. Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 15 Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion (Baptist, Roman Catholic and non denominational) if they wish. Discussions with the Manager highlighted that although the current residents fell into a specific age group and had similar religious beliefs, the home would welcome any potential new resident who has special cultural/religious/spiritual beliefs and would make provision to accommodate their needs. The home believes in promoting an equal and diverse culture among staff and residents. Contact with family and friends is positively encouraged with visitors being able to attend the home at any time and in accordance with the resident’s wishes. Residents spoken with confirmed this. Residents are treated with respect and there is a good rapport between staff of the home and residents. This was observed at the time of the inspection. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The home’s menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Mealtimes can be varied upon request and resident’s guests are also welcome to have meals at the home. Drinks and snacks are available at all times. Medical, therapeutic or religious diets are provided as needed. Of the twenty one service user surveys received three responded always, nine responded usually and nine responded sometimes to the question that asks ‘Do you like the meals at the home?’ Comments received include ‘meals could be more varied’, ‘the suppers are sometimes tasteless and the tea is often cold’, ‘it’s the same old thing week after week’, ‘meals can be varied according to which chef is on’, ‘meals are not served hot if when taken in ones room’ and ‘the dining service is excellent’. Residents spoken with said that ‘food is good and often you get too much on your plate’, ‘the food is good and varied’, ‘I like the food here, it’s always very nice’ and ‘I have no complaints about the food’. Cheneys DS0000028541.V308543.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect resident’s in the event of an allegation of abuse. EVIDENCE: The home has an established complaints procedure in place. The home has received one complaint in the past twelve months. This complaint is currently being investigated by the home. The CSCI have received one complaint, relating to the home, in the last twelve months, which has led to the current Adult Protection alert that is currently being investigated under the MultiAgency Procedures. From the section in the service user surveys received relating to complaints, this showed that ten ‘always’ knew who to complain to, eight responded ‘usually’, one responded ‘’sometimes’ and one responded ‘never’. One resident did not respond but commented that they do they do know who to complain to but that to date it has not been necessary. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Verification of nursing staff’s registration to practice is obtained from the Nursing and Midwifery Council (NMC) prior to nursing staff commencing employment. Staff have attended training in the Protection of Vulnerable adults within the last twelve months. This was evident from the staff files that were viewed and from staff spoken with during the inspection process. Staff said that they were confident that in the event of an allegation of abuse, they would know the correct procedure to follow. The home has a Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 17 copy of the East Sussex County Council Multi-agency Procedures for the Protection of Vulnerable Adults. The home are currently involved in one Adult Protection Alert. There have been no other Adult Protection alerts in the preceding twelve months. Cheneys DS0000028541.V308543.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home provides accommodation for residents that is safe, hygienic and odour free. EVIDENCE: The home has made improvements since the inspection of December 2005 to ensure that more suitable storage for wheelchairs has been arranged in order that residents have full use of their lounge area. The location and layout of the home are suitable for its stated purpose. The home is well maintained and all areas of the home, including the garden, are accessible to residents. The home has an ongoing plan of refurbishment in place. Residents spoken with said that they liked their bedrooms and that the communal areas of the home were comfortable and decorated nicely. One residents spoke of how they were due to move to a bigger bedroom where they can be more independent and how staff had ensured that the transition between rooms ‘was being run smoothly’. The home has an infection control policy in place and staff are trained in infection control procedures, this was confirmed by staff training records, by Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 19 staff spoken with and by observation of staff adhering to procedures. It was evidenced that a clinical waste contract is in place. Of the twenty one service user surveys received thirteen responded always, seven responded usually and one respond sometimes to the question that asks ‘Is the home fresh and clean?’. Comments received include ‘ bedrooms are excellent’, ‘beds are often not made until late morning’, ‘my bedroom is often not cleaned thoroughly’ and ‘sometimes rooms are not cleaned at weekends and beds often do not have the linen changed unless you specifically ask for it to be done’. Cheneys DS0000028541.V308543.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The home has a staff team that have the necessary skills and experience to the meet the needs of current residents. EVIDENCE: A competent staff team meets the resident’s needs. There is a staff rota in place, which details staff designations and hours of working. Of the twenty one service user surveys received two responded always, sixteen responded usually and two responded sometimes to the question that asks ‘Are the staff available when you need them?’ One resident did not respond but commented that ‘I have never had to ask but I have never been ignored either’. Other comments included that ‘ residents have to wait because the nursing patients get seen to first’, ‘there never seems to be enough staff on duty’ and ‘the presence of a manager at the weekend would be appreciated’. Staff and residents spoken with at the time of the inspection reported that often at peak times ‘the home felt short of staff’. Comments received highlighted that mornings, lunchtime and bedtimes were busy periods within the home and that care workers are often ‘rushed’ and feel that they ‘cannot look after everybody properly as a result’. Nurses reported that there are times when an extra care worker ‘would be appreciated’, whilst residents commented that ‘staff always seem busy at certain times’. Therefore a requirement has been made. The home has a permanent care staff team of twenty four care assistants, seven of which are trained in National Vocational Qualification (NVQ) level 2 or 3 in care. Whilst a further nine carers are due to commence training in the New Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 21 Year. This was confirmed in the homes Pre-Inspection Questionnaire and from staff training records viewed. Therefore the minimum ratio of 50 of care staff to achieve a NVQ in care by 2005 has not been met. A number of the current staff team are nurses from abroad who are employed as care workers. The home are currently in the process of developing a means of evaluating how these employees overseas nursing qualifications equate to an NVQ equivalent. The home has made improvements since the inspection of December 2005 to ensure that two written references are obtained and ID checks are undertaken on all staff employed. Staff recruitment files were viewed and it was evidenced that these files now contain all items required under the Care Homes Regulations 2001.The home has an Equal Opportunities policy in place and is an equal opportunities employer. A number of the current staff team are from abroad. All necessary visa and Home Office related documents were found to have been obtained and kept on file for these employees. Staff training records showed that over the last twelve months the home had provided a range of training, including Induction Training, Fire Training, Health and Safety, Moving & Handling, Infection Control and First Aid. Other training related to the needs of the resident’s such as nutrition, diabetes, continence, palliative care and tissue viability have also been undertaken. Registered Nurses spoken with at the time of the inspection said that they felt the training provided was good and provided them with the opportunity to achieve their Post Registration Education and Practice (PREP) requirements, as governed by the NMC. Cheneys DS0000028541.V308543.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this area is good. This judgement has been made using the available evidence including a visit to this service. The management and administration of the home is good, with evidence of consideration being given to resident’s choice and opinion. EVIDENCE: The Manager has many years relevant experience in caring for older people. The Manager is a qualified Registered Nurse and a qualified Registered Midwife and has achieved the Registered Managers Award. The Manager is currently in the process of applying for the necessary documents required, to undertake the CSCI registration process for becoming the homes Registered Manager. Residents, relatives and staff spoken with said that the Manager is friendly, knowledgeable, and approachable. There is a Quality Assurance policy in place, that involves an annual development plan and continual self-monitoring of the home by the Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 23 Organisation. Quality Assurance questionnaires are distributed to residents, their representatives and other interested parties on an annual basis. The results of which are not published but are made available to all upon request. Monthly unannounced (Regulation 26) visit reports are conducted and a copy of this report is sent to the CSCI Eastbourne Office. Staff and residents meetings are held, the minutes of which were viewed and were found to be detailed in content and included actions taken to address previous issues raised by staff and residents. As part of the homes Quality Assurance processes consideration must be given to the comments made by staff and residents during the inspection process. Therefore a recommendation has been made. The Manager reported that the home does not take any responsibility for any of the resident’s other finances and that most residents have family, friends or representatives who protect their financial affairs. Any monies held on behalf of the residents by the home, known as pocket money accounts, are appropriately maintained, with detailed records kept of all transactions made to and from each account and evidence of an annual audit of these records having been conducted. The home has made improvements since the inspection of December 2005 to ensure that a fuller record is maintained of fire drills undertaken, which includes a list of staff attending and an evaluation of the drill. From the PreInspection Questionnaire provided by the home it was evident that fire drills, fire alarm testing and fire equipment checks, water checks and Portable Appliance Testing (PAT) had been carried out. Accidents are well documented in the home’s accident book. However, it was evident that the home encourage staff and residents to utilise an alcohol based sanitizing lotion which is marked as ‘toxic’ and ‘irritant’, bottles of which were freely accessible to both residents and staff. Cans of air freshener labelled ‘highly flammable’ were also noted in the homes toilet and bathroom areas. Both products were not maintained in accordance with Control Of Substances Hazardous to Health (C.O.S.H.H) thereby increasing the risk of hazard to both residents and staff, therefore Immediate Statutory Requirements were made. Please note that between the two dates of the inspection the home has ensured that all care staff were in receipt of pocket sized hand lotion and that all air fresheners had been removed from the homes toilet and bathroom areas. Therefore Immediate Statutory Requirements had been made. Cheneys DS0000028541.V308543.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Cheneys DS0000028541.V308543.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 OP7 Regulation 15(1)(2) (c) Requirement That care plans are drawn up in consultation with residents or their representatives as appropriate and that where this is not practical, care plans reflect this. That all handwritten entries onto MAR sheets must be signed by two staff and an explanation for the handwritten entry entered onto the back of the MAR sheet. This is an immediate Requirement. That all medications administered, which are creams/lotions/ointments, must be signed for by the person who has administered the treatment. This is an immediate Requirement. That staffing numbers are monitored and are altered according to the level of need of all service users. That air fresheners are removed from all bathroom and toilet areas and are stored in accordance with the C.O.S.H.H Regulations. This is an DS0000028541.V308543.R01.S.doc Timescale for action 02/01/07 2. OP9 13 (2) 02/11/06 3. OP9 13 (2) 02/11/06 4. OP27 18 (1) (a) 30/11/06 5. OP38 13 (4) (a) (b) (c) 26/10/06 Cheneys Version 5.2 Page 26 6. OP38 13 (4) (a) (b) (c) immediate Requirement. That liquid alcohol hand sanitizer 26/10/06 dispensers must be deemed static and tamper proof or are removed from all bathroom and toilet areas. This is an immediate Requirement. 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. Refer to Standard OP7 OP7 OP7 Good Practice Recommendations That residents fluid balance charts are maintained appropriately and that all fluids taken and omitted by the resident is clearly recorded. That entries onto residents daily care records are reflective of the residents care plan. That staff who make entries onto residents daily care records, record the date, time and their job designation on each entry made, in accordance with the NMC guidance on Documentation and Record Keeping. That 50 of staff are trained to NVQ level 2 by the end of 2005. (This is outstanding from the previous inspection). That consideration is given to the comments made by residents during the inspection process and the comments detailed from the CSCI service user surveys. 4. 5. OP28 OP33 Cheneys DS0000028541.V308543.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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