Inspection on 12/09/07 for Chervil Cottage

This inspection was carried out on 12th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chervil Cottage 27/08/08

Chervil Cottage 29/09/06

Chervil Cottage 23/02/06

Chervil Cottage 04/08/05

Chervil Cottage 24/01/05

Chervil Cottage 27/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Chervil Cottage Brighthampton Standlake Oxfordshire OX29 7QW Lead Inspector Jill Chapman Unannounced Inspection 12th September 2007 10:30 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 Chervil Cottage DS0000013070.V348392.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. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chervil Cottage Address Brighthampton Standlake Oxfordshire OX29 7QW 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) 01865 300820 01865 300420 wendy.drewett@virgin.net Mrs Wendy Drewett Mr Mark Drewett Mrs Wendy Drewett Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admission of one named resident who is under the age of 65. Date of last inspection 29th September 2006 Brief Description of the Service: Chervil Cottage is a care home for up to 17 older people and is in the village of Brighthampton, about six miles from Witney. There are public transport links to Oxford and Witney. Communal areas include a lounge, a separate dining area and a conservatory. Bedroom accommodation is on the ground floor and is in single rooms, except for one double room that is available for couples who choose to share. There is an attractive garden that is well maintained. Mrs Drewett (joint owner) manages the home. Fees range from £620.00 - £670.00 per week. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.30 am and was in the service for five and a quarter hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector looked around the building and the garden, spoke to some residents in their rooms and to a group during a lunchtime meal. Discussion took place with the proprietor/manager and two staff on duty. Records relating to care, staffing and health and safety were sampled. The views of six service users, five relatives and three health professionals were recived via surveys sent out prior to the inspection. What the service does well: Prospective residents receive information about the home to help them decide whether to live there. A thorough assessment makes sure that the home only admits residents whose needs can be met. Residents and their relatives are happy with the care provided. Residents care and health needs are met, care plans are up to date. Diverse religious or cultural needs could be met if needed. Residents privacy and dignity are upheld and residents are treated with respect. Residents can participate in activities of their choice and the home will support them to follow their cultural or religious beliefs. Residents are supported to keep in touch with family and friends who are made welcome in the home. Residents benefit from a varied and nourishing diet and special dietry needs could be catered for. Residents and their relatives know that their concerns will be dealt with. Staff are trained in the Protection of Vulnerable Adults. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 6 Residents benefit from a well cared for home that is kept clean and hygenic. The proprietors are committed to continually improving the environment for residents. Residents benefit from enough staff to meet their needs. There is a stable staff team and residents appreciate the continuity of care. Recruitment procedures make sure only suitable staff are employed to care for residents. The home is well managed by an experienced owner/manager who lives on site and is accessible. The views of service users and others are sought to help develop the service. Staff feel well supported and are supervised on a daily basis. Most health and safety systems are in place and there has been an improvement in some areas. What has improved since the last inspection? What they could do better: Care records do not always evidence the good care practice being carried out and could be further developed. A relative thought that residents would benefit from occasional outings. Some improvements have been made to the medication procedures but others are still needed in the way it is administered and recorded to reduce potential risks to residents. The manager and senior staff could beneft from POVA training that helps them know the local safeguarding adults referral procedure. Further development of National Vocational Qualification training would make sure that staff are fully trained to meet residents needs. Undertaking NVQ level 4 in management and care and regular training updates would enhance the managers skills and help staff see the value of further training. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 7 The development of a formal supervision system would evidence the support given to staff and the development of their practice. A health professional thought that staff would benefit from some training on catheter care, nutrition and adequate fluid intake. Training in health and safety and risk assessment will help the manager and staff keep residents safe. A continuous record of accidents or incidents that result in any injury needs to be developed to give the manager the opportunity to carry out regular audits of accidents to identify any further needs or health and safety issues. 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. Chervil Cottage DS0000013070.V348392.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 Chervil Cottage DS0000013070.V348392.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive information about the home to help them decide whether to live there. A thorough assessment makes sure that the home only admits residents whose needs can be met. The home does not offer an intermediate care service so Standard 6 does not apply. EVIDENCE: A previous requirement to ensure that the home’s Statement of Purpose and Service Users Guide contain the information required has been mostly adressed. The Statement of Purpose has been updated since the last inspection and the majority of information is now included. The manager agreed to include the missing information. The home provides an initial information pack that contains some of the information specified and it is recommended that this document is developed further to include all of the information specified in Standard 1.2 for the Service Users Guide. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 10 Each resident has a contract of terms and conditions and copies of these were sampled. From residents files sampled it is clear that a comprehensive assessment takes place to make sure that the home can meet the needs of prospective service users. The manager visits service users in their home where possible and service users are invited to visit the home prior to admission. A months trial helps residents decide whether the home suits their needs. The home does not offer an intermediate care service so Standard 6 does not apply. Chervil Cottage DS0000013070.V348392.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are happy with the care provided. Residents care and health needs are met but records do not always evidence the good care practice being carried out. Some improvements have been made to the medication procedures but others are still needed in the way it is administered and recorded to reduce potential risks. Residents privacy and dignity are upheld and they are treated with respect. EVIDENCE: Following admission, the manager carries out further assessments of needs which include behaviour, mobility, continence, communication, cognitive and memory. Care plans are developed from these. Assessments and Care plans were sampled and gave good information to help staff meet the needs. Care plans are reviewed every six months and more frequently if needs change. The majority of residents have very low care needs but some have more complex needs. There is a format to record daily care given but at present this is only completed when a significant event occurs. Day to day care tasks, activities, visitors received, mood and appetite are not referred to although it Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 12 is clear that the manager and staff are attentive to these issues. It is recommended that daily records are kept to reflect that the care plans are being carried out and to evidence the good care practice that occurs within the home. As part of the post placement assessment, potential risks are identified and documented. These need further development to show more clearly the elements of the risks that have been considered and what steps have been taken to reduce the risk. For example bathing risk assessments should show that the risk of falling, scalding and drowning have been considered. There was good evidence that healthcare needs are met. Residents said that they receive a good service from the GP and District Nurses and the manager said they have a good working relationship with these health professionals. Records of medical appointments are kept on residents files and staff are alerted to any health issues at the handover at each shift. The home has a suitable system for the storage and administration of residents medication. Previous requirements to obtain a controlled drugs cabinet and a controlled drugs register have been met. A requirement to make sure that only staff with authorised access are holding keys to drug cupboards has been met. A recommendation regarding various stages of the medication process has been mostly carried out. Recommendations that the manager must add the process for the storage and adminsitration of controlled drugs to the home’s medication policy has not been carried out. A recommendation that the practice of dispensing medication into pots before taking the tablets to the service user and signing the MAR sheet before staff have witnessed the resident taking the medication has not been met. This practice increases potential risks to service users and should be reviewed. The owner manager confirmed that staff receive medication training from Boots and that they receive a medication induction. It is recommended that medication induction training be documented to evidence this. The residents charter highlights that residents have the right to privacy and dignity and to be treated with dignity and respect. Staff confirmed that they are made aware of this expectation during the induction period. In discussion with staff it was found that the manager reminds staff of these values in staff meetings. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users can participate in activities of their choice and the home will support them to follow their cultural or religious beliefs. Residents are supported to keep in touch with family and friends who are made welcome in the home. Residents benefit from a varied and nourishing diet and special dietry needs could be catered for. EVIDENCE: The home organises a programme of monthly actrivities that includes keep fit classes, craft afternoons, reminicense, musical entertainers, bingo, a visiting library service and cultural loans service. Residents said they like playing Bingo and get sweets for a prize if they win. Residents spoken with were satisfied with the activities on offer. One relatives survey suggested that the opportunity for regular outings would enhance the residents quality of life further. Holy communion is held in the home every month and the home would arrange transport for any residents who want to go to another church or religious service of their choice. The home does not currently have any residents with diverse religious or cultural needs but would be able to meet these if required. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 14 Service users and relatives confirmed that their visitors are made welcome at any time and that they are given a welcome tray of drinks and cake. Most relatives surveyed felt that the home communicates well with them. One relative felt that there could be quicker communication about health isssues. The home does not look after residents finances, some are able to do this themselves and others have relatives who help them. All residents spoken with were complimentary about the food provided. It was clear that staff know their likes and dislikes and a choice is offered if they do not like what is on offer for the main meal. The record of food needs to be developed further to show any alternatives taken from the main meal. Meals are prepared with fresh produce and there are three staff who cook at different times during the week. The manager confirmed that staff who cook the meals have had Food Hygiene training. Breakfast is served in residents rooms and they confirmed there is some choice as to when they prefer this. The inspector joined residents for a lunchtime meal, it was well cooked and appetising. Staff assisted where needed and there was a sociable atmosphere. Some residents choose to eat in privacy in their bedrooms. There is homemade cake at teatime and drinks are available whenever they are wanted. There are no specific cultural or dietry needs at present but the home could meet these if required. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives know that their concerns will be dealt with. Staff are trained in the Protection of Vulnerable Adults and futher training could help the manager and staff become more familiar with the local safeguarding adults referral procedure. EVIDENCE: CSCI has not received any information about complaints made about the home. Relatives and residents said they know who to talk to if they are concerned and said that any problems are sorted out quickly. There is a suitable complaints procedure in place and no complaints have been received by the home. Staff were aware of what to do if there is a complaint. The commision has not received any information about any safegauarding referrals relating to this home. Staff confirmed that they have had Protection Of Vulnerable Adults training. At the time of the inspection the manager appeared unclear about the local safeguarding adults refferal procedure but subsequently has confirmed that this information is available in the home. The manager has not had POVA level 2 training that is aimed at staff who would need to make a referral if a concern arose. It is recommended that the manager and senior staff undertake this training if it is available in their area. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well cared for home that is kept clean and hygenic. The proprietors are committed to continually improving the environment for residents. EVIDENCE: A tour of the building and garden showed that the premises are well cared for and homely. All residents bedrooms are on the ground floor and are of a good size and all but one have en-suite toilet and washing facilities. Resident bedrooms seen were personalised with their own belongings. There is flexible communal space, lounge, two conservatories (one off the lounge and one newly installed off the dining room) and small seating areas. There is a designated hairdressing area. The bathroom has an assisted bath and there are assisted toilets. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 17 There is an attractive garden, which is accessible with flat pathways and ramps from the main entrance/exit ways. The proprietors are committed to continually improving the environment for service users. There is an infection control policy and all staff have received infection control training. There is a laundry with commercial type machines and the washing machine has a sluice programme. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from enough staff to meet their needs. Further development of National Vocational Qualification training would make sure that staff are fully trained to meet residents needs. Recruitment procedures make sure only suitable staff are employed to care for residents. EVIDENCE: The manager has increased the deployment of care staff since the last inspection. There is an extra carer from 8am to 2pm, which gives a total of four staff over that period. There are two carers from 7am to 8am, three carers from 2pm to 3pm and two from 3 to 10pm. At night there is one waking night staff and the manager is on call on site to assist if necessary. The care needs of the majority of residents are very low and the staffing levels appear satisfactory to meet the current needs. There is a low turnover of staff and they tend to work regular shift patterns. Residents spoken with said they appreciate this because they know who to expect on shift. Residents were complimentary about the support they receive from staff. Relatives said that staff are superb, caring and that the low turnover of staff is very good. One suggested that it would be better for residents and visitors if staff wore name badges, so they can be easily identified. Three staff in the home have achieved National Vocational Qualification awards, but the home has not yet achieved the required level of 50 trained Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 19 members of care staff (NVQ level 2 or above). The manager said she is a qualified NVQ Assessor and could support staff to take this qualification. A previous recommendation that the percentage of carers with NVQ or above should be increased has not been met and has been outstanding since 4th August 2005. The manager should consider how this can be achieved so that carers can develop their skills and knowledge, thereby ensuring that residents have good care at all times. The home has a recruitment procedure in place that includes carrying out checks to make sure that potential staff are suitable to work with vulnerable residents. Staff files were sampled and it was seen that all checks had been carried out. A previous recommendation to make sure that full employment histories are obtained in order for any gaps in employment to be identified and checked, has been carried out. New staff spoken to said they were made very welcome when they started work in the home. Staff spoken with said they enjoyed working in the home and that everyone gets on well together. Staff files were sampled and show that staff have received a variety of training relevant to their jobs. A health professional thought that staff would benefit from some training on catheter care, nutrition and adequate fluid intake. New staff receive a Skills For Care induction and induction workbooks are verified by an external trainer. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed by an experienced manager and further training would enhance her skills. The views of service users and others are sought to help develop the service. Staff are well supported and supervised and the development of a formal supervision system would evidence this. Most health and safety systems are in place. Training in health and safety and risk assessment will help the manager and staff keep residents safe. EVIDENCE: The manager has many years experience in running the home since it first opened. She is committed to providing good care and residents and their relatives said the home is well managed. The manager lives on site and is accessible and has good working relationships with residents, relatives and staff. There was good written information supplied by the manager on the Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 21 Annual Quality Assurance Assessment requested by the Commission prior to the inspection. The manager does not yet have a qualification at level 4 NVQ in management and care (or equivalent) although she is a qualified NVQ assessor. It is recommended that she consider undertaking this training to further develop her skills and to help other staff to see the value of National Vocational Qualifications. The manager said she updates her practice by reading but is not able to demonstrate that she periodically undertakes training to update her practice. There were some examples from this inspection that show this would be beneficial (see Standards 18 and 38). The manager seeks feedback about the service from residents on a daily basis and service users said any problems are quickly solved. Formal surveys are sent out annually and the feedback is used to develop the service. The manager said she supervises staff on an informal day-to-day basis and staff confirmed that she addresses practice issues in regular staff meetings. Staff have annual appraisals to look at their performance. It is recommended that a system of individual planned and documented supervision is developed for care staff to cover the areas highlighted in the standard, staff should receive this a minimum of six times a year. Previous recommendations regarding health and safety matters have been met. There has been an improvement in fire safety training, fire safety check records, hot water temperature control and a company has been contacted to carry out a survey to look at whether there are any risks from Legionella. Temperature tests to hot water outlets are now carried out, they are checked and recorded monthly, and it is recommended that these be carried out weekly. A thermostatic control valve has now been fitted to the bath. An up to date electrical installation check has been carried out as recommended from the previous inspection. Records show that equipment in the home is regularly serviced. Health and safety records were sampled and were up to date. The manager said that the handyman carries out monthly health and safety audits and any deficits are addressed but no records of these are kept. It is recommended that this is carried out. There are no health and safety risk assessments in place and the Environmental health officer should be consulted to get advice on how to develop these. The manager and staff have not had health and safety training and this must be arranged. The manager must also undertake risk assessment training. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 22 Records of staff accidents are kept in an accident book that gives guidance on what should be recorded and what should be reported. The manager said that resident accidents are recorded in their contact sheet if they are not injured and in the district nurses’ record if an injury is sustained. The home must keep its own continuous record of accidents or incidents to residents, to show the date and time of accident/incident, where the accident/incident took place, details of any injury sustained, staff on duty at the time, what action was taken and whether medical treatment was necessary. This will give the manager the opportunity to carry out regular audits of accidents and to identify any patterns of changing needs for residents or any potential health and safety issues in the home. Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 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 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 2 X 2 Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 13.4 Requirement Individual risk assessments need further development to show more clearly the elements of the risks that have been considered and what steps have been taken to reduce the risk. Medication • Where possible give medication from its original container. • Sign a resident’s medication administration record chart after medication is given. Write a policy for the storage and administration of controlled drugs. Seek advice from the environmental health officer and develop health and safety risk assessments. Health and safety training must be arranged for the manager and staff. Version 5.2 Page 25 Timescale for action 12/12/07 2 OP9 13.2 12/12/07 • 3 OP38 13.4 • 12/12/07 • Chervil Cottage DS0000013070.V348392.R01.S.doc 4 OP38 (17(1) a Schedule 3 The manager must undertake risk assessment training. The home must keep its own continuous record of accidents or incidents to residents, to show the date and time of accident/incident, where the accident/incident took place, details of any injury sustained, staff on duty at the time, what action was taken and whether medical treatment was necessary. • 12/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations The percentage of carers with a NVQ in care (or equivalent) should increase. This recommendation remains from inspections of 04/08/05 and 23/02/06. That the home’s information pack document is developed further to include all of the information specified in Standard 1.2 for the Service Users Guide. That daily records are kept to reflect that the care plans are being carried out and to evidence the good care practice that occurs within the home. That a system of individual planned and documented supervision is developed for care staff to cover the areas highlighted in the standard, staff should receive this a minimum of six times a year. That recorded checks to hot water outlets are carried out weekly. That monthly health and safety audits are recorded and show what action has been taken to address any issues. The manager and senior staff undertake POVA level 2 training that helps them know the local safeguarding adults referral procedure, if it is available in their area. 2 3 4 OP1 OP7 OP36 5 6 7 OP38 OP38 OP18 Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Chervil Cottage DS0000013070.V348392.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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