Inspection on 04/08/05 for Chervil Cottage

This inspection was carried out on 4th August 2005.

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 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 23/02/06

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 Jan Walsh Announced 04 August 2005 09:30 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 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 H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Chervil Cottage Address Brighthampton, Standlake, Oxfordshire, OX29 7QW Telephone number Fax number Email 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 Wendy & Mark Drewett Provider/Manager Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admission of 1 named resident under the age of 65. Date of last inspection 24 January 2005 Brief Description of the Service: Chervil Cottage ia 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 H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector visited the home on an announced inspection lasting 5 hours. During this time a tour of the building and grounds was made and the home was seen to be bright, clean and well maintained. The kitchen and two weeks’ menus were also seen. Eight residents were spoken with who made very positive comments about their home and its management. A senior member of staff was spoken with and the manager interviewed. Three residents’ records of care and four staff records were looked at in detail. Ways of improving documentation and record keeping in line with the minimum care standards were discussed. Very favourable comments had also been received from a health professional and from residents’ comment cards. What the service does well: What has improved since the last inspection? The home’s communal areas have been redecorated and the residents said how pleased they were with the results. Some improvements have been made in staff records with photographs of the staff now included and the recording of staff training more evident. The faulty fire door has been repaired after the last inspection. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 6 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. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 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 standard(s) 3, 4 and 5 Residents and their families are encouraged to visit the home prior to admission to assess the home as a suitable placement and to know the home will be able to meet the prospective resident’s needs. The manager assesses the prospective resident’s needs at this time, or will visit them at home or in hospital if this is more practical EVIDENCE: The manager explained the procedure for admitting residents to the home and how she assessed the home’s suitability and their needs during a visit prior to admission. Written evidence was seen of assessment dated shortly after admission. Residents confirmed they visited before admission so they knew the home would be a suitable place in which to live. They confirmed they met the manager/proprietor at this time. One lady said she lived locally and had visited the home several times before she became a resident. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The residents’ health and welfare needs are assessed and most residents have few needs, as they are fairly independent and self-caring. Residents are treated with respect. The home ensures that the healthcare needs of the residents are fully met. The home stores and administers medication safely. EVIDENCE: The residents spoken to felt they had the best possible care and that all their care needs are met. Very positive comments were received from the GP. Written evidence was found in the residents’ records examined, of GP involvement, community nurses and chiropodist and other requested specialists. The residents confirmed they regularly saw the GP and the district nurses. Health problems are recorded in a resident log or in the resident’s records. Two new residents’ records showed evidence of assessment with no problems identified. One record of a resident who had been admitted for some time showed problems identified and the involvement of the specialist health service team. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 10 The medication was seen to be stored tidily and safely in a locked medicine cupboard. Medication records were examined and found to be accurate with the morning medication administered and signed for. No residents are selfmedicating and there are no controlled drugs used. Written evidence was seen that staff designated to administer medication have recently attended a medication course. Residents confirmed they were treated with respect and this was also observed during the inspection. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13 and 15 Residents are encouraged to join in social activities and to maintain contact with their family and friends. Residents enjoy wholesome meals in the two attractive dining areas or in their own rooms as they wish. EVIDENCE: The manager explained how residents were encouraged to join in activities and that members of the community also came in to entertain them. Residents’ relatives are encouraged to visit and are always made welcome. Residents confirmed this. Residents spoke of the different activities that were open to them. They particularly mentioned the exercise group and keep fit. They spoke also of a gentleman that visits and brings his portable organ to entertain them. They also confirmed they had newspapers if they wished. Some residents liked to sit in their rooms, others liked to sit in the sitting room or conservatory. One lady was sitting out in the garden, and said she spent as much time as possible in the garden. She had her own plot outside her room but was finding it difficult to look after lately. Some of the residents said they had moved here to be near their relatives and that their relatives were always made welcome with tea and cakes. The residents also confirmed they had cultural loans from a local museum. This included a gentleman coming to the home with a box of items from the museum to talk to the residents about them. The last subject had been the war and he was due next week to visit Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 12 and talk about the seaside. Several residents said they very much enjoyed this and were looking forward to the next visit. The residents were very keen to say how good the food is. Several of them made this a particular point. On the day of inspection they had lamb chops and vegetables and this was followed by fruit crumble. Several of the residents said it was delicious and the lamb chops very tender. The residents confirmed there was always an alternative if they did not want what was on the menu. One resident said he did not like liver but there was always something different for him. The menus for the two weeks seen showed a good selection of nutritious meals with two roasts a week and lighter cooked suppers in the evening. One resident always had sandwiches in the evening, as she prefers this. The kitchen was seen on the tour of the building. This was clean and tidy. The cook confirmed she had recently retaken her Food Hygiene course. She confirmed there was some flexibility when meals were taken. She said one gentleman likes his breakfast at 6am. The manager confirmed that as they are a small home they are able to meet individual requests. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16, 17 and 18 Residents know how to complain if necessary. The home protects the residents’ rights and makes sure they are protected from abuse. EVIDENCE: The home has had no complaints since the last inspection. Residents confirmed they and their relatives can always speak to the manager or another member of staff. They confirmed they are confident that any concern would be listened to and acted upon. The manager confirmed she is always available to speak to residents and to their relatives. Residents confirmed they had voted in the last general election if they had wanted. Three residents confirmed they had a postal vote. The manager confirmed all staff had had abuse training and that new staff had abuse training as part of their induction. Written evidence was seen to confirm this and that the staff signed during their induction to say they understood the whistle blowing policy. All staff are given a copy of the Oxfordshire Multi-Agency Codes of Practice for the prevention of abuse. The residents confirmed they know who to speak to if they have any concerns and that they will be listened to. The manager confirmed that the home does not have any involvement with the residents’ finances. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 24 and 25 Residents live in a comfortable well-maintained environment with their personal possessions around them. However the radiators and pipe work have not yet been covered and there is no system to control the hot water temperature to the baths and wash basins, therefore raising the potential risk to residents. EVIDENCE: A tour of the building showed that it is clean, well maintained and attractively decorated. The residents confirmed that the communal areas have recently been decorated and they said they were very pleased with the results. The furniture and fittings are of a tasteful domestic type. There are several different communal areas in which residents can sit. The garden is well maintained and has wheelchair access. One resident was sitting out in the garden on the day of inspection. She confirmed she went out into the garden as often as she was able. She had had an area of garden to cultivate outside her room but now was no longer able to attend to it. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 15 Residents confirmed they could bring in their own possessions to furnish their rooms. Examples of this were seen with the residents’ permission on the tour of the building. The radiators and pipe work have not yet been covered as recommended at the last inspection; however the manager confirmed they were waiting for the handyman to fit them. Water to the washbasins and baths does not have a control system to prevent the water being delivered at above the recommended 43oC. The manager confirmed risk assessments were in place. One risk assessment seen was not dated or signed. It is recommended that the proprietors investigate ways of controlling the temperature of the hot water in line with the care standards. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 Staff are cared for by adequate numbers of trained and competent staff. It is recommended that new staff are registered on a certified induction course to cover all areas of care practice and help staff towards their NVQ. Poor recruitment practices give rise to a potential risk to residents. EVIDENCE: On duty on the day of inspection were three care staff, one cook and the manager as the senior, which is appropriate to the assessed needs of the residents. No staff member is under 18 years. A copy of the week’s rota was seen. The manager confirmed that staff were working towards NVQ 2 but that 50 had not yet achieved this. All new staff were expected to start NVQ 2 within a period of time after their induction. Two new staff members have had induction training and written evidence was seen of this. The manager also confirmed they worked alongside a senior carer for a week under supervision before they work alone. The home uses its own introduction programme, but it is recommended that the new staff are registered on a certified programme to ensure all areas of care are covered and this will help staff towards their NVQ Staff receive ongoing training in the home and also in external training courses, evidence was seen of this. Evidence was seen of first aid training, Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 17 manual handling, food hygiene, fire safety, medicine administration. Staff also confirmed this. Two new members of staff have been recruited since the last inspection. One reference only had been received for one staff member though another had been requested twice. Both members of staff had a Criminal Records Bureau (CRB) check from a previous employment only. No copies of identification such as birth certificate, passport if any, were kept in any of the staff records as required by the care standards. Letters confirming employment were not conditional on CRB, Protection of Vulnerable Adults (POVA) data list checks or on receiving satisfactory references. It is a requirement that the home has robust procedures for recruitment of staff to verify that the person is a fit person to work with vulnerable adults. These include checking the identity of the person, getting valid references and POVA First and CRB checks before the person starts work. (The person may work under supervision while waiting for CRB clearance if all statutory checks have been received). Copies of birth certificates and a current clear photograph should be kept in the files with a copy of the passport and any work permits. If a birth certificate cannot be obtained the Commission for Social Care Inspection should be informed, further identity evidence obtained and a note made in the member of staff’s records. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 The home ensures the staff have regular supervision and the home promotes the health, safety and welfare of the residents and staff. It is recommended that the staff supervision is also used as a time for staff development. EVIDENCE: Evidence was seen in staff files of regular supervision. However it is recommended that this time is also used for talking with the member of staff and looking at their development needs for the benefit of the staff member and the home. Evidence was seen of regular staff training in safe practices such as moving and handling, food hygiene, fire safety, first aid and safe medication administration. Accident book was seen with appropriate recordings kept in the resident’s file. Written evidence was seen of risk assessments. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 2 x STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x 3 x 3 Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? 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 29.3 Regulation 19 (1) a,b Requirement The home must have robust recruitment procedures and ensure that no member of staff is employed until all proofs of identity have been obtained and a copy kept as stated in Schedule 2. No person should be employed until all statutory checks have been made plus two verified references received, one from the last employer. Timescale for action Sept 05 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 25 (5)(8 Good Practice Recommendations It is recommended that the radiators and hot water pipes are covered as soon as possible. It is also recommended that the manger seeks advice on controlling the hot water temperatures to reduce any risk to residents. 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 H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 21 2. 28(1)(3) Chervil Cottage 3. 36.(3) 4. 5. after the induction period to help gain the required percentage of qualified staff for the home. It is recommended that supervision time is also used to look at staff development to ascertain the requirements of staff to fulfill their roles competently and what further goals they may have. None. None. Chervil Cottage H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 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 H57-H08 S13070 Chervil Cottage V231538 040805 Stage 4.doc Version 1.40 Page 23 - 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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