Inspection on 23/02/06 for Chesham House

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 Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chesham House 30/05/07

Chesham House 12/12/06

Chesham House 07/06/05

Chesham House 07/03/05

Chesham House 27/04/04

Similar services:

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

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

CARE HOME ADULTS 18-65 Chesham House 151 Newmarket Road Norwich Norfolk NR4 6SY Lead Inspector Mrs Hilary Richards Unannounced Inspection 23rd February 2006 10:20 Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 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 House DS0000028593.V283895.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chesham House Address 151 Newmarket Road Norwich Norfolk NR4 6SY 01603 452226 01603 452229 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) Mrs. Penelope Baily Jane Elizabeth Olivier Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Chesham House is a care home registered to accommodate a maximum of 6 persons in the category of mental disorder. It is linked to a specialist clinic Baskerville House (a Private Healthcare Facility located next door to the premises), for persons who have experienced eating disorders. Once patients at the clinic are sufficiently progressed in their recovery, they are offered a period of temporary residence at Chesham House. It is anticipated that service users will be supported and enabled to complete their rehabilitation at this care home prior to attaining their independence and moving back into the community. During their stay, service users receive on going psychiatric care, therapy and support as appropriate to their needs. Additional charges made are related to the consultants fees in respect of mental health care services purchased on behalf of the service user. Chesham House is a large period residence located in a mainly residential area to the south of Norwich city centre. The property stands back from a main road, secluded by mature trees and walled gardens, and is approached by a driveway with some private car parking places. Service users accommodation is within single rooms, located on the first and second floors, with access to bathroom facilities alongside. All city amenities are easily accessible, by bus or on foot and service users can if they wish park their own vehicles in the grounds. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection that took place on one day and lasted for 3.5 hours. The focus of the Inspection was the key standards not covered in the home’s first Inspection this year and to follow up the requirements made during that Inspection. The Inspector spoke extensively with the acting deputy manager and a selection of records was examined. The three service users in placement at the time of this Inspection were all ill on this particular day and were therefore only spoken to in passing. Two of the service users had been spoken to at length during the previous Announced Inspection. The accommodation was not specifically assessed but the majority of the home was viewed during the course of the Inspection; the previously high standard of accommodation was noted to have been maintained. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed as part of this Inspection. EVIDENCE: Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10 The individual needs and choices of residents are fully reflected in their Service User plans; plans contain clear targets and goals and are regularly reviewed. All information within the home is handled appropriately and confidences are kept. EVIDENCE: Two case files were sampled during the course of the Inspection. One file was for a relatively new service user to the unit and the other related to a woman who had been in placement during the previous Inspection. Both files contained Individual Therapeutic Plans (ITP) that detailed specific targets and goals and evidenced regular updating and review. Both files held specific risk assessments in relation to known and likely behaviour; these assessments also evidenced regular review. Residents continue to be encouraged to fully participate in the community and undertake the usual range of social activities for young adults as evidenced by recording on file. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 9 As noted during the previous Inspection, the unit has clear guidance to staff and residents regarding confidentiality of information. Recording on case files and discussion with staff evidenced that policies and procedures are adhered to in practice. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed as part of this Inspection. EVIDENCE: Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed as part of this Inspection. EVIDENCE: Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service Users are listened to and are protected from abuse, neglect and selfharm. EVIDENCE: The home has an appropriate Complaints Procedure in place that is contained within the Service User Guide to the home. The staff team hold regular Community Meetings with residents and the manager is available to service users and staff on a daily basis. Comments made by residents during the previous Inspection of the home this year evidenced their confidence that the manager would resolve any issue to their satisfaction. The home has not received any formal complaints since opening. The home has appropriate procedures in place with regard to adult protection and whistle-blowing. The record of staff training evidenced that the majority of the staff team have also attended specific POVA training. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home is clean and hygienic. EVIDENCE: The majority of the Environment standards were not specifically assessed as part of this Inspection but all communal areas of the home were seen during the course of the visit. The level of accommodation offered by the home continues to be of a high standard, is well maintained and is clean and hygienic throughout. Residents at the home are responsible for their own laundry and a domestic washing machine and tumble dryer are available for their use. Staff are responsible for the laundering of communal items such as tea-towels. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 The recruitment process for the home is not wholly satisfactory. Service users’ needs are met by appropriately trained staff. EVIDENCE: Chesham House has not employed any additional staff since the previous Inspection although some staff who had previously worked at Baskerville House, also owned by Newmarket House Clinic, now work at Chesham House as bank staff. The administrator for the clinic advised that staff files have not been updated to evidence the requirements of Schedule 2 of the Care Homes Regulations 2001. The two staff files that were seen did not evidence proof of identity, including a photograph. The Inspector confirmed that all new members of staff must have a CRB Disclosure completed by the clinic prior to starting work; written guidance was provided following the Inspection to clarify the issue of portability in relation to CRB Disclosures. The staff training records in the home evidence that all staff undertake comprehensive and relevant training in relation to the specific needs of the service users at this establishment. All staff have now completed Basic First Aid training, as required following the previous Inspection. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42 The home seeks the views of service users to inform the development of practice within the home. The health, safety and welfare of service users are promoted but action is required in relation to the home’s fire safety procedures. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 16 EVIDENCE: The home has an annual development plan in place that is informed by the views of the residents who use the service. The development plan is reviewed annually by the manager. The Health and Safety records within the home evidence that all equipment is serviced at appropriate intervals and that weekly fire alarm tests take place; the home has not undertaken a fire drill within the previous 6 months. The most recent inspection report by the Fire Service, dated 09.09.04, required the fire doors on the dining room and breakfast room doors to be fitted with automatic closures or to be kept shut at all times. Neither door has been fitted with an automatic closure and both doors were wedged open during the course of this Inspection. Staff advised that these doors are routinely wedged open as this enhances the domestic environment that the home provides. Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 4 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 3 X X 2 X Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 18 YES 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 YA34 Regulation 19 Requirement The Registered Provider must ensure that staff personnel files evidence all the requirements of Schedule 2. (Previous timescale of 07/06/05 not met) The Registered Provider must ensure that fire doors in the home are not wedged open. The Registered Provider must ensure that Fire Drills take place at a minimum of 6 monthly intervals. Timescale for action 01/05/06 2. 3. YA42 YA42 23 23 23/02/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chesham House DS0000028593.V283895.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Chesham House DS0000028593.V283895.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!