Inspection on 23/02/06 for Chervil Cottage

This inspection was carried out on 23rd February 2006.

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 12/09/07

Chervil Cottage 29/09/06

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 Kate Harrison Unannounced Inspection 23rd February 2006 10:15 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.V284058.R01.S.doc Version 5.1 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.V284058.R01.S.doc Version 5.1 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 Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admission of one named resident who is under the age of 65. Date of last inspection 4th August 2005 Brief Description of the Service: Chervil Cottage is a care home for up to 17 older people and is registered with the CSCI. The home is located in half an acre of landscaped gardens in the village of Brighthampton, about six miles from Witney. There are public transport links to Oxford and Witney. All service user accommodation is on the ground floor, and is in single rooms, although couples can share if they wish to. Many of the bedrooms have doors opening onto the garden, which offers opportunities for related hobbies and relaxation. Communal areas include a lounge, two separate dining areas and a conservatory. The home is family owned and one of the proprietors is the registered manager. The manager is supported by a local staff team, which improves the continuity of care for the service users. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one morning and early afternoon and was unannounced. This was the second inspection of the service since April 2005. The registered manager was on duty and there were 14 residents in the home, one of whom was in hospital. The inspector saw all areas of the home, spoke to staff and discussed issues with the registered manager. The inspector discussed life in the home with seven residents, and heard their views on the care and services they receive. Only those key standards not assessed at the announced inspection on 4th August 2005 were assessed at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The residents are at risk from scalding from the hot water in hot water taps and this needs to be quickly addressed. The radiators and hot water pipes need to be covered as soon as possible. New staff who have no care qualifications need to be registered on a certified induction course. A washable finish should be applied to the walls of the laundry room. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 6 Disinfectant gel should be provided in the laundry room so that staff can disinfect their hands. A pedal bin should be provided in the laundry for the disposal of gloves and aprons. Staff should attend infection control training. The registered manager needs to gain the NVQ Level 4 qualification. The plans to regularly monitor the quality of the service need to be carried out. 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. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were assessed at the announced inspection on 4th August 2005 and were not assessed at this inspection. EVIDENCE: Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 9 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): The key standards were assessed at the announced inspection on 4th August 2005 and were not assessed at this inspection. EVIDENCE: Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 10 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): 14. Residents are able to choose how to lead their lives within the home. EVIDENCE: The inspector spoke to 7 residents who told the inspector that they felt at home and were able to exercise choice about what they could bring into the home. One resident showed the inspector her room and said she was very pleased with it, and another said that he was able to bring his own bed with him. The registered manager said that relatives or care managers take responsibility for financial affairs when residents are no longer able to do so, and the home does not get involved in residents’ financial affairs. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 11 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): The key standards were assessed at the announced inspection on 4th August 2005 and were not assessed at this inspection. EVIDENCE: Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 12 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): 26. Some measures need to be taken to improve infection control. EVIDENCE: The inspector saw the home’s laundry, situated near the kitchen, and as there are no hand-washing facilities in the laundry room recommends that gel be provided so that staff can disinfect their hands. Staff use protective clothing but it is not clear that staff have had training on the prevention of infection. The home should have an infection control policy giving current guidance for staff on how to prevent infection in the home. A pedal bin should be provided for the disposal of gloves and aprons. The walls in the laundry need to be washable, and the inspector recommends that a suitable finish be applied. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 13 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): The key standards were assessed at the announced inspection on 4th August 2005 and were not assessed at this inspection. EVIDENCE: Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 14 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 and 38 was partly assessed at this inspection. The registered manager is skilled and experienced, but needs to gain the NVQ Level 4 qualification. The home’s quality assurance system is informal and needs to be formalised. Residents’ financial interests are safeguarded. Safety issues remaining from the previous inspection have not been addressed. EVIDENCE: The registered manager is also one of the joint proprietors, and is skilled and experienced in running the home. She intends to enrol on the NVQ Level 4 programme soon, but as she has not yet gained the NVQ Level 4 the inspector is required to grade the standard as ‘2’. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 15 The home’s quality assurance programme is informal and based on the good relationships between residents and staff. The registered manager sees residents regularly, mostly on a daily basis, and is able to quickly address any issues. The registered manager discussed plans for improving the quality assurance system, including residents and relatives meetings, and staff meetings. She also intends to introduce an annual survey of residents and relatives about all issues affecting the lives of residents in the home. The home does not manage residents’ financial affairs, and secure facilities are provided for residents’ valuables. The inspector noted that the temperature of the water in the hot tap in the bathroom near the lounge was too high, and presented a risk to the vulnerable residents. The registered manager must address this risk of scalding from hot water. The inspector noted that all radiators and hot water pipes accessible to residents are not protected. This was discussed with the registered manager, and although some risk assessments are in place a recommendation was made at the time of the last inspection and remains to be done. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 17 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 OP38 Regulation 13 (4) Requirement The risk of scalding from the hot water accessible to residents must be eliminated. Timescale for action 24/02/06 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 OP25 Good Practice Recommendations It is recommended that the radiators and hot water pipes are covered as soon as possible. This recommendation remains outstanding from the inspection of 4th August 2005. It is recommended that new staff, without qualifications, are registered on a TOPPS certified induction course to enable them to gain the knowledge to care competently. It is also recommended that staff are registered for NVQ in Care after the induction period to help gain the required percentage of qualified staff for the home. This recommendation remains from the inspection of 4th August 2005 and is being addressed. A washable finish should be applied to the walls of the laundry room. Disinfectant gel should be provided in the laundry room so DS0000013070.V284058.R01.S.doc Version 5.1 Page 18 2. OP28 3. 4 OP26 OP26 Chervil Cottage 5 6 7 OP26 OP26 OP26 that staff can disinfect their hands. A pedal bin should be provided in the laundry for the disposal of gloves and aprons. The home should have an infection control policy giving current guidance for staff on how to prevent infection in the home. Staff should attend infection control training. Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Chervil Cottage DS0000013070.V284058.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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