Inspection on 28/11/06 for Chepstow House

This inspection was carried out on 28th November 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chepstow House 19/01/06

Chepstow House 29/07/05

Chepstow House 24/02/05

Chepstow House 15/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Chepstow House Old Maids Walk Ross on Wye Herefordshire HR9 5HB Lead Inspector Christina Lavelle Unannounced Inspection 28th November 2006 11:30 Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 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 Chepstow House DS0000041406.V321673.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 Adults 18-65. 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. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chepstow House Address Old Maids Walk Ross on Wye Herefordshire HR9 5HB 01989 566027 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) Chepstow House (Ross) Limited Ms Sally Keene Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users may also have physical disabilities in addition to their learning disabilities. Service users may also have a mental health disorder that is associated with their learning disability. Service users must be at least thirty years of age. 19th January 2006 Date of last inspection Brief Description of the Service: The current provider was registered in August 2003 and set up a company to operate the home. This company has two directors, one of whom (Kevin Betts) is the approved responsible individual for the home. They are registered jointly in respect of four other care homes, two of which are also in Herefordshire. The company’s head office is at Park View House, 59 Thornhill Road, Streetly, West Midlands B74 3EN. The manager (Sally Keene) was registered in March 2004. Chepstow House offers accommodation with personal care for fourteen people (men and women). Service users must be aged at least thirty and some are over sixty-five. They must require care due to learning disabilities and can also have physical disabilities and/or a mental health disorder that are associated with their learning disability. Service users may also use behaviours that can challenge a care service and have limited communication and social skills. The home’s main stated purpose is to provide a homely environment for service users and to encourage them through education and stimulation to achieve as much as they can, in a way that is generally valued by society. The home is a large, detached house set in a quiet location within easy walking distance of the centre of the market town of Ross-on-Wye. The original house has been substantially extended and was previously used as a doctor’s surgery. All bedrooms are single with four on the ground floor and six on the first floor in the main part of the home. Two bedrooms have en-suite facilities including a shower and there is a separate four-bedded flat on the ground floor. There are two sitting rooms for service users (the lounge in the flat also has a dining area) and a separate dining room in the main home. The garden is at the front of the house and has a patio area. There are parking spaces at the back and a small internal open courtyard, which is used as the smoking area. The current fee for the service ranges from £494.00 to £2,180.00 a week, depending on individual’s needs. Additional charges are made for such as dry cleaning, newspapers, personal clothes & toiletries, hairdressing, private health care e.g. chiropody, contributions to holidays and additional transport i.e. taxis. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a key inspection of Chepstow House which means the inspector checked all the Standards that can have most effect on the service users. This was a surprise visit and took six and a half hours during the daytime on a Tuesday. Time was spent with service users and those able to communicate were asked about their lives and if they like Chepstow House. The manager discussed the home and how it is run and three staff were spoken with on their own. They were asked about their jobs, training and experience and about service users and their care. Everyone was welcoming and very helpful with the inspection. Some records that must be kept by care homes and parts of the house were looked at. All information received by the Commission about the home since the last inspection is also considered. This includes events that had affected service users and copies of reports made following the provider’s monthly visits to the home to check it is being run properly. One matter was notified by the home and also referred under local protection of vulnerable adults procedures as it could affect the safety of a service user. It was decided the home should investigate, which they did so thoroughly and appropriate action was taken. The manager had completed a questionnaire before this visit with useful details about the current service. Six of the service users, three of their relatives and one health care professional had also sent in survey forms showing their views of the home. Some of their comments are referred to in this report. What the service does well: There is good information to give possible new service users and the manager also meets them to check the home could be suitable. They are able to visit and try out the home to ensure they would like to live there before moving in. Service users help to make a plan of their care so staff know their needs and goals and how to meet them. Staff check any possible risks and plans also show staff how to keep service users safe and what to do when they are upset. It was nice and friendly in the home and service users and staff seem to get on well. Service users say they are happy living there and like the staff. Each has a special staff member (keyworker) who give them more personal support. Keyworkers also help service users to keep in touch with their families. Their relatives feel they are made welcome in the home by staff, one commenting:“I find Chepstow House very helpful to X and myself” and another:“I am so grateful for the care and love given to X”. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 6 Service users get any help they need with their personal care. Staff support them to stay well, have health care checks and manage their medicines safely. The home is in a good place near to Ross-on-Wye town so service users can walk easily to shops, cafes, pubs etc. The home has two vehicles for outings. Chepstow House offers service users a very comfortable and safe home. The house is well kept and was found to be warm, clean and tidy. Service users who wanted to have made their bedrooms nice and personal. Training is arranged for staff so they know about and understand service users special needs and can help to keep them safe and support them better. The manager has the right skills and experience and the home is run well. Staff say they receive good support from the manager and the staff team work together to make sure service users have good care. The way the home is run is checked and plans are made to keep improving it. What has improved since the last inspection? 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. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. There is written information about the home to help prospective service users (and/or with their representatives) decide if they would live to live there. Thorough assessment and admission procedures are in place to help to make sure that the home could suitably meet the needs of new service users. EVIDENCE: The home provides a statement of purpose, a service users guide and terms & conditions of residence documents. The guide is available in a suitable format with simple language, pictures and photographs so prospective service users with learning disabilities can understand it easier. Two service users confirmed they were asked about moving in and were given information about the home. Although there has not been a vacancy for a while the manager described the processes of assessment and admission the home would follow. This includes visiting prospective service users to meet them and assess their needs. A copy of a community care assessment made by their social worker would always be obtained, as well as information sought from their families. Whenever feasible introductory visits to Chepstow House would then be arranged, followed by a trial stay. Review meetings are held after a trial period with all relevant people involved before fee and support levels are agreed and the placement confirmed Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users receive good support from staff who help them make a plan to meet their needs and wishes. They are able to make choices in their daily lives and routines. Staff consider possible risks and how to minimise and manage risks for service users’ safety and welfare whilst promoting their independence. EVIDENCE: A sample of service users care records was checked and include a pen picture, their photograph and background information. Each person appropriately has a written plan covering all relevant aspects of their care needs. Plans include short and long term goals with an action plan as to how and who would help to meet them. The home has adopted a suitably “person centred” approach to care planning so service users preferred daily routines, likes/dislikes, strengths and dreams are also ascertained and are part of their plans. Service users are involved in drawing up their plans and, when able to, have signed them. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 10 Staff also make detailed daily reports and a record of all significant events in service users’ lives. This provides information about their health, welfare and progress, which is very helpful when their needs and plans are being reviewed. Service users each have a keyworker from the staff team. Staff interviewed are clear about their keyworker role, which involves spending more individual time getting to know their allocated service users and their needs and wishes better. They help them with clothes & toiletries, arrange activities and holidays and to keep in touch with their families. Keyworkers are also expected to take an active role in care planning and review plans monthly with service users. The home also reviews plans six monthly and a formal review meeting is held annually, when families and significant other people are invited to participate. Appropriate risk assessments have been carried out; some cover general areas such as support needed with bathing, mobility and when out in the community. Others are more individualised and relate mostly to service users’ behaviour. Techniques for staff to minimise self-harming and aggressive behaviours are described, such as distraction, and to promote more positive behaviour. Only in exceptional circumstances is physical intervention to be used by staff and in this event there is a specific policy for each service user involved. Behavioural care plans detail the problem and the desired outcome, with an action plan. As part of this process staff are expected to complete a behavioural analysis sheet and incident forms. If necessary an accident form is also completed. Service users are encouraged to make choices in their daily lives, although some older service users have very set routines. Service users meetings are held monthly (which about half the group take part in) when they are involved in making decisions about day-to-day issues. The home has tried to find local advocates to support individual service users (particularly those without regular family contact). However as they are not available four service users now belong to a local advocacy scheme and attend their monthly meetings and social events. The home has also joined up with a national advocacy group, which has sent service users leaflets and packs. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are enabled to take part in activities they enjoy, which includes mixing in the wider community and developing their social and independent life skills. Staff also support service users to maintain links with their families. Staff aim to promote a healthy diet for service users, although this could be improved when their nutritional assessments are reviewed and a Dietician is consulted. EVIDENCE: Service users plans include an assessment of their social and emotional needs and interests. It is good that their skills and any encouragement and support needed from staff to motivate them and keep them active are also shown. An activities list has been drawn up based on this information, including in-house activity sessions, activities in the community and involvement in household tasks. One person’s plan shows they like music, gardening, football and regular walks and another attends a cookery class and a farm project at local colleges. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 12 The pre-inspection questionnaire lists in-house activities service users can take part in e.g. arts & crafts, music & movement sessions, games, letter writing, video evenings and independent living skills. In the wider community activities include going for walks, the cinema, Leisure Link, day services, bowling and helping with household shopping. The home has two vehicles for outings and those who want to go on holiday; two service users went abroad this year. Today some service users were out at their day services and one person was supported to attend a college session. Others were sat in the lounge with the television on, looking at magazines and/or snoozing. Staff sat in the room and chatted to them and/or accompanied them out for walks. The manager said some service users do not take part in specific activities due to their condition. Some are older and frail and so activities for their personal development, such as college courses and work placements, are not appropriate. Others find it difficult to engage in activities and interact with other people. However their care records should show how they have spend their time and that staff do try to encourage and support them with meaningful activities. Also whether they have enjoyed, benefited or refused activities. Keyworkers help service users maintain links with their families. Relatives are positive about this and say they are always made welcome in the home. One parent said staff were very supportive when they were ill and kept in touch and arranged visits etc. Some service users have friends at their day services and meet them at Leisure Link. Staff encourage this, inviting them to socials at the home and arranging regular socials with service users from other care homes. Regarding food provision staff produce a 4-week menu and said they know what service users like/dislike and they can choose an alternative if they wish. Breakfast was shown to comprise of cereals and toast and lunch mostly stuff on toast or sandwiches. The main evening meal includes two roasts and some pasta dishes each week. However there seems to be quite a few convenience meals e.g. pizza, fish fingers and faggots. Staff said they try to encourage healthy eating and the manager said a Dietician had previously gone through the home’s menus and made some suggestions. For example offering service users more fresh fruit and vegetables, however service users are not keen on fruit. The manager is to consult the Dietician again about a new winter menu. Lunch today was poached eggs on toast but a service user’s food intake record showed they had scrambled eggs on toast yesterday and a meal including fried eggs the day before. Whilst this person does refuse food attention should be paid to providing a varied diet. Service users did have nutritional assessments carried out and special needs are recorded such as portion size and food cut up with staff assistance/oversight required. These should be reviewed with input from the Dietician who was consulted in respect of two service users who have recently lost weight due to physical and behavioural causes. However it would be better if there is specific written guidance for staff in relation to their meals. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are being supported by staff to meet all their personal and health care needs and staff are managing their medicines safely in the home. It would help to confirm that service users’ health needs are being monitored; also that their good health is promoted and preventative steps taken if they each have an individual Health Action Plan. EVIDENCE: Service users’ plans include an assessment of their personal care needs and the help each person needs from staff to meet them. Records are also kept when service users have received any personal care and in respect of physical checks carried out when necessary, such as their weight and food intake, Care records provide information about the service users medical history and current health care needs. Also of routine and specialist health care checkups and input including from GPs, district nurses, chiropody, well person clinics and a Psychiatrist. One health care professional indicated in a comment card that the home communicates clearly with them. Also that there is always a senior Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 14 staff member to confer with, they can see their patients in private and that staff understand service users’ needs. It is considered good practice by the Department of Health for people with learning disabilities to each have a Health Action Plan. These plans can help to ensure and confirm their health is being monitored, any problems identified and their good health is promoted. This would include showing all their special health care needs are understood and recognised and they are helped to stay healthy through preventative as well as routine & specialist health care input. Regarding medication there are policies & procedures in place that also reflect relevant guidelines for managing medicines safely in care homes. Service users’ ability to consent to medication and self-administration are appropriately considered. There are suitable storage facilities for medicines in the home and records or medications kept and administered are being maintained properly. Medicines are audited weekly and a community Pharmacist visits regularly to check the home’s system and management. There is a list of staff authorised to administer medicines and staff only do so when they have undertaken accredited training for safe handling of medicines. Two medication errors have been notified to the Commission since the last inspection and were dealt with appropriately by the home. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. There is a suitable framework in place for service users to express their views and concerns and appropriate steps are taken by the home for their protection. EVIDENCE: The home provides a complaints procedure that is also in a format people with learning disabilities are more likely to understand i.e. with simple language and pictures. A copy was seen in a service user’s bedroom and four service users confirmed in their surveys they would know who to raise any complaints and worries with and feel confident they would be listened to and action taken. A notification was made to the Commission since the last inspection regarding allegations from a service user about a staff member. This was referred under Herefordshire multi-agency protection of vulnerable adults (POVA) procedures. It was decided that the home would investigate and the matter was dealt with appropriately. There are policies & procedures in relation to abuse and adult protection, (including whistle blowing) and the home also has a copy of the Herefordshire POVA procedures. Staff receive relevant instruction during their induction and are expected to consider any incidence or suspicion of abuse or neglect at the end of every shift and compete a form to raise any issues if necessary. A training session was also held this year taken by the POVA co-ordinator. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 16 Service users money is managed safely by the home. An individual record of each person’s savings is kept and any cash spent by them (or by staff on their behalf) is accounted for. Staff ensure that receipts are kept and that two staff check cash spent, with their signatures, to confirm transactions and the daily cash balance held by the home. Only one service user can manage their own cash and they have a lockable money tin and can lock this in their bedroom. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Chepstow House offers service users a secure and comfortable home, which suitably meets their needs. There are appropriate arrangements in place to keep the accommodation clean, well maintained and continually improved. EVIDENCE: Chepstow House is in a convenient location near Ross-on-Wye town and the building fits in unobtrusively with other local housing. The overall impression of the accommodation is comfortable and the house was warm, clean and tidy. There is a cleaning rota for staff to ensure household tasks are completed. Improvements to the property are ongoing and several bedrooms and one sitting room had recently been redecorated. The sofas in the main lounge still need to be replaced however and the sooner the better as they are rather low for service users with poor mobility to get up and down even with staff support Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 18 The few bedrooms visited have been well personalised. One service user has a new fish tank and was very pleased with it and said he likes his bedroom. There are policies & procedures relating to good hygiene and infection control. The home appropriately involved the Health Protection Agency in relation to a specific situation recently. A protocol has subsequently been set up, with their input, for staff, which they were observed to follow. Some staff completed a comprehensive distance-learning course on infection control through a local college and all new staff receive instruction as part of their induction. Disposable gloves and aprons are provided for staff and there are arrangements in place for the disposal of soiled waste. Suitable hand wash facilities are available, including anti-bacterial liquid soap and paper towels. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are supported by sufficient staff who are suitably experienced and qualified and/or receive relevant training and support to help them know, understand and meet their care and special needs properly. Overall the home follows a thorough recruitment process including taking up necessary checks to ensure staff are suitable, for service users protection. This will be improved when more information is obtained as part of applications. EVIDENCE: Staffing levels are being maintained at an appropriate level to meet service users’ needs. Rotas show there are normally five support staff on duty from 7.00am to 9.00pm and the manager mostly works weekdays in addition to care staff for the management task. It is positive that the home is now fully staffed and so agency staff are not having to be deployed. Permanent staff are more likely to know the service users and their needs better and provide more consistent support. Also to be more committed to the home and service users. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 20 The recruitment process was discussed with the manager and a sample of staff records checked. The records appropriately include copies of relevant personal documents and each person had two written references and a CRB/POVA check taken up, as required. It was noted however that the completed application form does not request a full employment history and for any gaps to be explored and explained, as is now required. The manager said the provider is introducing a new form to ensure the relevant information is obtained. A fairly new staff member was interviewed and described how they completed an application from, attended an interview and that necessary checks had been taken up. They had read all the home’s policies & procedures but had not yet attended all the core training e.g. moving & handling or food hygiene. Their induction had included them going through the home’ induction programme and shadow shifts. They are to start the LDAF induction course soon. The provider has produced a comprehensive induction programme, which all new staff must complete. It covers health & safety topics, the principles of care, supporting service users and all other areas relevant to a care service and to service users’ special needs. All staff are also expected to complete the LDAF induction training, which is accredited especially for people working in care with people who have learning disabilities. Most staff had already achieved an NVQ qualification in care and others will progress to NVQ following LDAF induction. Each staff member has a training record, which includes records of individual supervision held two monthly and they will also have an annual appraisal. Other relevant training sessions have been arranged such as autism awareness, dementia, epilepsy and positive interventions for the management of challenging behaviours. Staff interviewed feel there is good communication within the team and they are kept informed and supportive of each other. There are shift handovers, a staff communication book and team leaders keep support staff updated. Staff and service users meetings are also arranged. They feel the manager is open and listens and takes their views into account. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home is well run by an experienced and qualified manager. There is an open and positive management approach that helps to ensure service users’ individual rights are respected and they receive a good service. Appropriate steps are taken to keep the home safe and so protect service users and staff. Systems are in place to monitor and review all relevant aspects of the service. This results in a plan for its continual improvement, which should also involve service users and other interested parties in the way that the home develops. EVIDENCE: The registered manger (Sally Keene) was registered in respect of the home in March 2004. She is suitably experienced and qualified, having achieved an NVQ 4 qualification in care and management. She is committee to training and hopes soon to attend a course to enable her to become a first aid trainer. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 22 The home employs a deputy and an assistant manager who have delegated management tasks such as supervising care staff, as well as taking day-to-day responsibility in the manager’s absence. The manager also feels the home is well supported by the provider. The director and other company staff are always available to give advice and they carry out the required monthly visits. Monthly meetings are also held with other care home managers. These include relevant training sessions about such as employment issues from the company operational manager who also provides individual supervision for managers. The provider operates a comprehensive formal quality assurance & monitoring system. This includes a monthly quality audit, covering all relevant aspects of the service and resulting in an action plan to address any identified shortfalls. The representative of the provider who visits the home monthly crosschecks the audits and monitors how the home is being run by observing and talking to service users and staff. This all leads to an annual development plan for the service outlining the areas to be developed; the action required with timescales and those responsible. The provider recognises the need to consult with service users and significant other people as part of this process. This is being addressed through service users meetings and obtaining the views of service users’ families, and should be extended to include other stakeholders. Regarding health & safety the home ensures that staff undertake all mandatory training topics i.e. first aid, fire, moving & handling, infection control and food hygiene. Staff had all recently attended a fire drill. The pre-inspection questionnaire confirmed regular maintenance and servicing of gas and electrical installations. Records kept in the home showed that staff are undertaking fire safety checks as required and risk assessments had been carried out and/or are in place, including COSHH. Also checks related to the environment e.g. water temperatures are made regularly for the protection of service users. There were no hazards observed in the environment during these inspection visits, and overall it is apparent the home pays due attention to promoting and ensuring the safety and welfare of service users and staff. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered persons meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement Staff employed to work at the home must submit a full employment history (with any gaps explored and a satisfactory explanation given) before their appointment is confirmed. Timescale for action 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the registered provider to consider carrying out. No. 1 2 3 Refer to Standard YA17 YA19 YA24 Good Practice Recommendations The home’s menus and service users’ nutritional assessments should be reviewed in consultation with a Dietician. Health Action Plans should be set up for service users. More suitable seating should be provided in the main lounge as soon as possible. Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Chepstow House DS0000041406.V321673.R01.S.doc Version 5.2 Page 26 - 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. 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