CARE HOMES FOR OLDER PEOPLE
Chesham Bois Manor Amersham Road Chesham Bucks HP5 1NE Lead Inspector
Christine Sidwell Unannounced Inspection 6th September 2007 11:30 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 Chesham Bois Manor DS0000022960.V350323.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. Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Chesham Bois Manor Address Amersham Road Chesham Bucks HP5 1NE 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) 01494 783194 01494 794636 chesham@bmcarehomes.co.uk B & M Investments Limited (Trading as B & M Care) Mrs Elaine Ward Care Home 48 Category(ies) of Dementia (31), Old age, not falling within any registration, with number other category (48) of places Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 48 residents, 31 of who may have dementia. Date of last inspection 15th November 2006 Brief Description of the Service: Chesham Bois Manor is situated a short distance from the town centre of Chesham, a small town which provides a variety of shops and other local amenities. Chesham is served by local bus routes and has a Metropolitan Line tube station and main line services. The home is one of several run by B&M Care Limited, and provides accommodation for up to 48 elderly Residents, 31 of whom may require additional support due to dementia type illness. All Service Users are accommodated in single bedrooms, 23 of which have ensuite facilities. Communal areas consist of various lounges, dining and quiet areas. The home is an older building with a modern extension. There are extensive, and well-maintained grounds, including a secure garden area where service users with dementia type illness can walk in a safe environment. A team of carers, a deputy manager, housekeeping and catering staff, support the homes manager, and access to healthcare professionals, including community nurses, is by direct contact or through General Practitioner referral. The fees range from £350 to £750 per week. Additional costs are incurred for chiropody, hairdressing and personal items. Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted over the course of three days and included a one day unannounced visit to the home. The key standards for older people’s services were covered. Information received about the home since the last inspection was taken into account in the planning of the visit. Prior to the visit the manager completed an annual quality assurance self-assessment. Information from this was taken into account in the planning of the inspection. Questionnaires were sent to residents, their families and healthcare professionals. Two residents, eight family members and three healthcare professionals returned the questionnaires. Residents and families were also spoken to on the day of the unannounced visit. Discussions took place with the manager, nursing, care and ancillary staff. Care practice was observed. A tour of the premises and examination of some of the required records was also undertaken. The homes approach to equality and diversity was considered throughout. What the service does well:
The care needs of potential residents are identified with them, prior to their move to the home, to ensure that they can be met. Residents and their families have the opportunity to visit to the home and the manager or deputy visits them in their current residence, be that at home, in another care home or in hospital, before they move. Residents’ personal, healthcare and medication needs are met and their autonomy and dignity is protected. Resident’s care plans are developed with them and kept up to date. Local general practitioners visit regularly and there was evidence that residents have access to local primary care services and hospital specialists when necessary. Medication management is satisfactory. Routines are flexible and residents are encouraged to adopt the lifestyle that would prefer, as far as they are able. There is a range of activities available to residents who have a choice as to whether they participate. The standard of meals is high and residents’ nutritional needs are met. There is a choice of main course at lunchtime. Food is home cooked and drinks are offered frequently. The chef was aware of residents individual likes and dislikes and meets residents regularly. Special diets to meet resident’s cultural or religious preferences could be made available if required. The complaints policies and procedures work well and residents and their families feel that any concerns that they have are addressed promptly. There are safeguarding policies and procedures in place. And staff have received training in this topic and said that they would have no hesitation in reporting
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 6 any concerns. The Commission for Social Care Inspection has not received any concerns or complaints and has not been notified of any safeguarding allegations made to the local authority under their procedures. Residents live in an attractive, safe and well-maintained environment. There are attractive gardens, which are being upgraded to provide better outside access. Improvements are also planned for the dementia care unit. Infection control standards are high and have been reviewed in the line with the latest Department of Health guidance to help protect residents from acquired infection. Residents are encouraged to personalise their rooms and many have chosen to do so. There are sufficient, well qualified staff to meet resident’ needs in a timely and competent manner. Staff have an induction period when they work alongside experienced carers and undertake training in safe working practices. The recruitment procedures are thorough and references and Criminal Records Bureau disclosures are obtained for all members of staff. Staff are supported to obtain National Vocational Qualifications in Care at level 2 and fifty percent of care staff have achieved these. There is an experienced manager in post. Residents’ views about the quality of the service offered are listened to and acted upon. The quality assurance systems are to be further developed to include regular audit of care and procedures to ensure that high standards are maintained. There are health and safety policies and procedures in place and staff have had training in safe working practices, including moving and handling, food hygiene and infection control. Families who returned the questionnaires were positive about the home. One said that the home was ‘well run with helpful staff’, another that ‘they really look after individual needs and work well with relatives’ and another that ‘overall an excellent home, well run’. What has improved since the last inspection? What they could do better:
It is recommended that all staff who administer medication should undertake an accredited medication administration course in addition to the ‘in house’ medication administration course to give them greater knowledge in this area.
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 7 Confirmation that the Protection of Vulnerable Adults register has been checked (POVA first) before a staff member starts work should be kept to verify that it has been undertaken if a member of staff commences work before the full Criminal Records Bureau disclosure is received. 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. Chesham Bois Manor DS0000022960.V350323.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 Chesham Bois Manor DS0000022960.V350323.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): 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The care, social and cultural wishes of potential residents are identified with them, prior to their move to the home, to ensure that they can be met. EVIDENCE: The files of four residents were examined. All had evidence that the manager had visited them prior to their move to the home and their needs had been assessed. The residents spoken to said that they had received enough information about the home before they moved and had had the opportunity to visit or stay for a short period prior to moving. The families who returned the questionnaires said that they had been given enough information about the home and one commented that the manager and her staff were ‘very approachable’. There is reference to potential residents’ religious and cultural needs in the assessment documentation. The home does not offer intermediate care. Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 10 Chesham Bois Manor DS0000022960.V350323.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 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents’ personal, healthcare and medication needs are met and their autonomy and dignity is protected. EVIDENCE: The care of four residents was followed through in detail. Their files contained comprehensive care plans and the staff spoken to were knowledgeable about their care. The care plans had been reviewed regularly and updated when appropriate. The residents who returned the questionnaires and those spoken to on the day of the unannounced visit said that they were involved in planning their care and that the staff were responsive to their wishes. The risk of residents acquiring pressure damage due to immobility is assessed and the appropriate equipment is made available. Nutritional risk assessments had been undertaken. The staff and chef were aware of residents dietary needs and could provide special diets when necessary. There was evidence in the files that residents are weighed regularly. Continence assessments are undertaken and appropriate aids are provided by the Primary Care Trust, (PCT). No residents have developed pressure damage since moving to the home. Residents register with local general practitioners who visit the home
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 12 regularly. Three general practitioners returned the questionnaires and all said that staff had a clear understanding of residents needs and that their advice was incorporated into the care plan. Records of falls are kept and families confirmed that they are notified appropriately. There was evidence in the files that falls assessments are undertaken and that residents are referred to their general practitioner or the local hospital or primary care specialist nurse should individual residents fall frequently. Both the residents who returned the questionnaires said that they always or usually received the care that they need and that the staff listened and acted upon what they say. The families who returned the questionnaires said that the home always or usually met the care needs of their friend or relative. One added that the staff were ‘very caring’. Another said that the staff ‘are caring, helpful and willing with always a kind word and smile’. There are medication policies in place. Storage facilities are satisfactory. Records are kept of medication entering and leaving the home. The medication administration records were accurately completed. Controlled drugs were stored satisfactorily. A contract is held for the safe disposal of unused medication. The carer spoken to said that medication was not administered covertly. If a resident refused medication this would be recorded. If the medication was essential and the resident lacked the capacity to make to the decision, the doctor and family would be informed and a way forward agreed. The pharmacy provider has been changed recently and staff have received training from the new provider in the management of the medication system. All staff have ‘in house’ training and their competence is assessed before they give medication. One member of staff had had accredited training at the local college, which he felt was very helpful. It is recommended that all staff who administer medication undertake accredited training in medication management and administration The staff were observed to be treating the residents with respect and their dignity was protected. All care is given in residents’ rooms. The general practitioners said that they saw residents in their rooms. Residents said that they enjoyed the privacy of the home and had a choice as to whether they stayed in their rooms or joined other residents in the lounge or dining room. Chesham Bois Manor DS0000022960.V350323.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 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Routines are flexible and residents are encouraged to participate in the activities offered to bring interest and diversion to the day. The standard of meals is high and residents’ nutritional needs are met. EVIDENCE: There is an activities coordinator in post. Her hours have been increased to 25 hours per week since the last inspection. She is a member of a national association of activities organisers and gets ideas from them as well as from residents. The manager holds regular residents form meetings when residents have the opportunity to influence the programme. A visit from a local farm and owl centre proved popular. An activity schedule was displayed which showed that a range of activities was available every day of the week. Carers are encouraged to help with activities in the afternoons. Activities include music and movement which one resident said she particularly enjoyed. The residents who returned the comment cards said that they enjoyed the atmosphere in the home and could join in if they wished. They said that they had a choice as to how they spent their day. Families spoken to said that they were welcome at any time and were always called when necessary. Residents are helped with their personal care in their
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 14 rooms and the GP who returned the questionnaire said that he could always see his patient in private. The statement of purpose states that visitors are welcome at any time and that the home supports residents to remain in contact with family and friends. The meals are of a high standard. All the residents who returned the questionnaires said that they enjoyed the food. There was evidence from minute of the residents’ forum that residents have input into the menus. A choice of main course is offered. On the day of the unannounced visit several residents who did not like either choice were offered alternatives. The food is home cooked and meals are spread throughout the day. One lady spoken to said that ‘she was never hungry’ and looked forward to mealtimes. Mealtimes were observed to be a sociable occasion. The downstairs dining room is being redecorated and refurbished which will improve the mealtime experience for residents with dementia. Carers were seen to be helping those who were unable to eat unaided, discretely and sensitively. Chesham Bois Manor DS0000022960.V350323.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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The complaints policies and procedures work well and residents and their families feel that any concerns that they have are addressed promptly. There are safeguarding policies and procedures in place, which should protect residents from harm. EVIDENCE: There are complaints policies and procedures in place. A record is kept of all complaints including verbal concerns. The manager said that there have been no formal written complaints made to the home since the last inspection. All the families who returned the questionnaires and the residents spoken to said that they knew who to talk to if they had any concerns. One commented that ‘whenever we have had concerns the manager and senior staff have been most helpful and supportive’. There are safeguarding policies and procedures in place and the manager was aware of the local authority procedures. Records showed that staff have had training in the protection of vulnerable people. The staff spoken to confirmed this and said that they would have no hesitation in reporting any concerns. One family member who returned the questionnaires said that ‘they keep my relative safe from everyday risks’. The Commission for Social Care Inspection has not received any concerns or complaints and has not been notified of any safeguarding allegations made to the local authority under their procedures.
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 16 Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 17 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Residents live in an attractive, safe and well-maintained environment. Infection control standards are high and have been reviewed in line with the latest Department of Health guidance to help protect residents from acquired infection. EVIDENCE: The home is in an attractive older building and has a new extension. It is situated in attractive landscaped gardens. There is a programme of ongoing refurbishment and four bedrooms have been refurbished this year to provide ensuite facilities. Residents are encouraged to personalise their rooms and most had chosen to do so. There are handrails in corridors and hallways. Window restrictors are fitted to upper floor windows and radiators are covered to protect residents should they fall against them. The dementia care unit is safe and all external doors are alarmed should someone try to leave. A bid has been supported by Buckinghamshire County Council to improve the gardens and the dementia care area. The manager stated in the annual
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 18 quality assurance self- assessment submitted as part of this inspection that their plans for improvement in the next twelve months included completing the outside to a good standard to enable residents to go outside more often and incorporating a designated activities room in the downstairs dementia care unit leading to an outside courtyard area. The home has been inspected by the Buckinghamshire and Rescue Service and has agreed the improvements to fire safety that were required. There are infection control policies and procedures in place. The manager has a copy of the latest guidance on infection control in care homes published by the Department of Health and has undertaken the self-assessment that was recommended by the department and has recognised that procedures could be improved by staff training. This is being implemented. Alcohol hand disinfectant is available and the manager said that hoist slings were not shared. Staff were observed to wash their hands and there is soap and hand towels in resident’s rooms for use by staff and visitors. The laundry is well organised and clean and is sited away from the kitchen. There are procedures for separating soiled laundry. The washing machines are old and staff commented that they did not always remove stains. One family member raised his in the questionnaires stating that ‘it seems that stains are not coming out and that delicates may be damaged’. The manager hoped that a new washing machine would be provided over the next twelve months. Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 19 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 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. There are sufficient, well qualified staff to meet resident’ needs in a timely and competent manner. The recruitment procedures are thorough although not all relevant documents were retained for inspection, which should be addressed. EVIDENCE: On the day of the unannounced visit there were forty-four residents in the home. There were eight care staff on duty throughout the day and the manager said that there would four waking staff at night and one asleep on call if required. In addition some afternoon staff came in at 12 noon to give extra cover over the busy lunchtime period. In addition one of the morning staff would start at seven am to help at a busy morning time. This is good practice and demonstrates that staff work flexibly to meet residents’ needs. The manager also undertakes night shifts. The care team are supported by a team of housekeepers and laundry and catering staff. The carers said that they were not required to undertake additional tasks and could concentrate on the care of residents. The night staff do help by keeping the washing machines going but are not required to undertake other tasks. The recruitment files of four staff were examined. All held application forms, proof of identity and interview records. Two references had been sought before the staff member started work. Criminal Records Bureau (CRB) disclosures had been sought for these staff. The manager stated that she undertook the ‘POVA first’ check and did not start anyone until that had been
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 20 received as clear. The notification that the person was not on the Protection of Vulnerable Adults register was not kept once the full CRB disclosure had been received and was satisfactory. This meant that it was not possible to verify at the unannounced visit that the Protection of Vulnerable adult register had been checked prior to the staff member starting work. The ‘POVA first’ email notification should be kept for inspection purposes if a staff member starts work before the full CRB disclosure is received. The manager stated that staff have a two-week supernumery induction period and commence an induction programme which meets the Skills for Care standards. The staff spoken to confirmed this. The training records showed that staff had training in safe working practices. Of the thirty-four care staff, seventeen hold the National Vocational Qualifications in Care at level 2 or above, meeting the standard that fifty percent of staff hold this qualification. Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 21 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, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence, including a visit to this service. The home is safe and well managed. Residents’ views about the quality of the service offered are listened to and acted upon. The quality assurance systems are to be further developed to include regular audit of care and procedures to ensure that high standards are maintained. EVIDENCE: There is an experienced manager in post. She is a registered nurse and also holds the National Vocational Qualifications in management at Level 4. The staff spoken to said that the manager was approachable and spent time with residents and their families. The proprietors are implementing a quality assurance programme in all their homes, which this home will participate in. The manager said that it was intended that the system be fully implemented within the next year. There is a clear audit schedule which is planned to start
Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 22 in October of 2007. The operational managers, who visit the home, will validate the audits undertaken by the manager and her team. There was evidence that regular visits are made to the home by the company and a record of those visits is kept in the home. The manager has undertaken a residents and family questionnaire but has not yet analysed the results and produced an action plan, which she stated would be completed by the end of October. There are regular resident’s forums, which seek to obtain the views of residents and incorporate them into the way in which the home is run. The home does not manage residents’ money on their behalf. There is secure storage available for residents to keep a personal allowance in the home and records were seen to verify that records are kept and receipts are given when small amounts of money are left with the home for safekeeping. There are health and safety policies and procedures in place. At the last inspection some of the annual service and safety checks on appliances and services had not been carried out and records had not been kept. This has been rectified and service records were in place for all major services and appliances. Fire safety records are kept and staff had had fire awareness training. The fire alarms are tested regularly and electrical systems were serviced and small appliances were checked. The staff spoken to were aware of fire evacuation procedures. Training records showed that most staff have had training in safe working practices, including moving and handling and food hygiene. Chesham Bois Manor DS0000022960.V350323.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 X X 3 X X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Chesham Bois Manor DS0000022960.V350323.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP18 Good Practice Recommendations Staff, who administer medication, should undertake an accredited course in the administration of medication. Confirmation that the Protection of Vulnerable Adults register has been checked (POVA first) before a staff member starts work should be kept to verify that it has been undertaken if a member of staff commences work before the full Criminal Records Bureau disclosure is received. The organisation’s new quality assurance programme should be fully implemented. 3 OP33 Chesham Bois Manor DS0000022960.V350323.R01.S.doc Version 5.2 Page 25 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: 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
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