Inspection on 27/04/04 for Chesham House

Care Homes For Adults (18 ­ 65)Chesham House151 Newmarket Road Norwich Norfolk NR4 6SYUnannounced Inspection27th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Chesham House Address 151 Newmarket Road, Norwich, Norfolk, NR4 6SY Email address Tel No: 01603 452226 Fax No: 01603 452229Name of registered provider(s)/company (if applicable) Mrs. Penelope Baily Name of registered manager (if applicable) Mrs Heather Cracknell Type of registration Care Home No. of places registered (if applicable) 6Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (6) Registration number I070000007 Date first registered 1st May 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 NO YES 28/08/03 If Yes refer to Part CChesham HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 327th April 2004 02:40 pm Mark GowerID Code149062Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs Jane OlivierChesham HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementChesham HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Chesham House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Chesham HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Chesham house is an independent residential care home that specialises in the treatment for young adults affected by eating disorders. The home is registered for six service users that are accommodated in a large Victorian building with six large single rooms. There is plenty of additional communal space such as lounge, dining area exceptional large kitchen with additional dining areas, and two other comfortable seating areas one of which is used for private consultation when required, an activity room on the top floor and a conservatory. The home is located in the suburbs of Norwich and has a large well-maintained garden and is within easy access to facilities within the city centre. Chesham house serves as the second stage of treatment following the successful treatment at a sister home, which is next door (153 Newmarket Road) and is registered by the Commission Healthcare Audit and Inspection as a Private Healthcare Facility. The home in intended to be for short-term care and to promote the independence of the service users to live an independent life.Chesham HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection lasting approximately 4.30 hours. Due to the inspection being unannounced it was not possible to assess all the elements under each standard. The score given represents those aspects viewed on the day and which are commented upon within the text of the report. It was possible to have discussions with service users the homes manager and view samples of files and documentation. A tour of the premises was conducted and the inspector used general observation skills throughout the inspection. The inspector felt comfortable and reassured that the home is providing a good service to the service users that they are responsible for. All the standards assessed during the inspection met the standard. Below is a summary of how the home fared under each section: Choice of Home (Standards 1 - 5) All the standards in this section were assessed and all met the criteria. It was clear that the home prides itself on providing a specialist service and provides clear information to allow the service users to make informed choices. There is clear evidence that the home is meeting the needs of the service users and the homes statement of purpose and service user guide provides succinct information about the service. Individual Needs and Choice of Home (Standards 6-10) All the standards were assessed during this inspection and all standards were met. It is clearly evidenced that throughout the discussions and viewing the homes documentation that each individual service user is provided with the appropriate information to make decisions and take responsibility for those decisions which is respected and encouraged at all times. A recommendation was made in relation to daily notes to provide a tighter system. Lifestyle (Standards 11 ­ 17) All the standards in this section were assessed and met the criteria. Service users are encouraged to express their own interests and develop a lifestyle at the home that suits their individual personality and needs. Evidence of service users being involved in a range of social, educational and work-based activities was seen. Personal and Healthcare Support (Standard 18 - 21) Three of the standards were assessed during this inspection and all the met the standard. All service users are independent in areas of personal care and are enabled to access Chesham House Page 6 services when necessary. All service users who currently reside at the home are selfmedicating and there is clear documentation and systems in place to monitor the outcome of this process. Concerns, Complaints and Protection (Standards 22 ­ 23) Standard 23 was assessed and met the standard. It was subject to a requirement at the last inspection however it is evident that a lot of work has been undertaken to follow up on the requirement. They have clear procedures and an outline of responses in the event of adult abuse allegations. Environment (Standards 24 - 30) Six of the standards were assessed during this inspection and all six met the standard and in some instances exceeded the standard. The inspector was impressed by the high standard of accommodation and the warm and relaxed atmosphere that is achieved at Chesham House. Staffing (Standard 31 - 36) Standards: 32, 33, 35 & 36 were assessed during this inspection and all four standards met the criteria. There is regular staff training available and a number of events were displayed throughout the home. The staff have access to a range of experienced professionals based at 153 Newmarket Road. There are clear support mechanisms in place to provide staff supervision and support. Conduct and Management of the Home (Standard 37 - 43) Standards 38 and 42 were partly assessed and met the criteria. It was not possible to gain access to relevant information relating to staff, as this was an unannounced inspection. However, it was evident throughout the inspection that the management promotes the importance of creating an open, positive and collaborative home.Chesham HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Chesham HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that information documented about service users on a daily basis is recorded separately to effectively maintain confidentiality should service users want to see their own records and enable the tracking and follow through of care provision.1YA10Chesham HousePage 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Chesham House YES YES NO YES YES NO NO NO YES YES NO NO YES YES NO NO NO YES NO YES 3 0 X NO NO YES YES X X Page 10 Date of inspection Time of inspection Duration of inspection (hrs)27/04/04 14.40 4.30The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Chesham HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? A full statement of purpose has now been devised and incorporates all the relevant information detailed in schedule one of the regulations. A requirement made at the last inspection regarding the homes statement of purpose has now been fully actioned. The home also has a clear service users guide that is written in plain English and accessible to the service users. It incorporates information relating to the statement of terms and conditions which all service users are expected to sign and agree. Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All referrals to Chesham House are made from the sister establishment next door. It is intended to act as the next resource for service users who are recovering following their treatment in 153 Newmarket Road. Clear links are made between both establishments and a thorough assessment and pre admission programme are completed before transfer from 153 Newmarket Road to Chesham House.Chesham HousePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home provides a specialist service and demonstrated the skills, knowledge and experience that they have in the specialist area of eating disorders. Evidence gathered during this inspection, through discussion with service users and staff, inspection of records and the general feel of the home, clearly indicate that Chesham House is meeting the assessed needs of the service users. It is noted that a consultant psychiatrist completes a fortnightly review with the service users and a member of staff. Counsellors and therapists continue their involvement throughout the service users stay in the home. Service users stated to the inspector that they really value the counselling support and that they consider the home to be by far the best from their experience as they help from within and not just the practical things such as getting your weight back up and then discharging. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The manager of the home informed the inspector that each service user who is admitted to Chesham House is always transferred from their sister home at 153 Newmarket Road. An explanation of regular meetings and agreements before a decision to have a trial period takes place was provided. Regular visits are arranged and subsequent overnight stays until a final transfer takes place. It was evident that this process is organised with the service users at the forefront of their minds and the process from commencement to the final transition varies which is dependent on individual need. The Home has transfer procedures that match the description provided by the manager. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The home has a clear criterion for admission that service users agree to and sign prior to admission. The format is understandable as it is written in a way that is non-threatening and accessible to all the service users at the home. The service users informed the inspector that they find the pack that they receive prior to admission very useful.Chesham HousePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has a comprehensive individual therapeutic plan (service user plan), including current goals and plan of action. It was evident that these are reviewed and revised on a regular basis to allow for the changing needs of the individual person. Service users expressed about the regular meetings and involvement that they have in the development and reviews of their individual plans. Documentation was seen which included the dates and signatures of relevant parties involved such as service user and key worker. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? There was evidence of choice and empowerment within service users records and policy documents. On discussion with service users it was clear that they felt staff enabled them to be independent and to take personal responsibility for such things as finances and medication, but were there to support and advise when appropriate. The service users felt included in all areas of their life at the home and that staff respected their decisions.Chesham HousePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? There was significant evidence both on the service users file and with documentation kept around the home that service users are able to participate in the day-to-day management of the home. Each service user has a list of activities that they participate in or have responsibility for as well as attending regular meetings to reach decisions about the running and management of the home. Everyone that the inspector spoke to on the day of the inspection showed great motivation and enthusiasm for the service that is either being provided or received. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Each service user has documentation on the level of risk that is presented in certain areas. The home has clear policies and procedures in place to update on any situation that will action further risk assessments and outcomes. The information seen on the day of the inspection was well documented.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The manager stated that the information held about the service users is kept in confidence. This was seen on the day of the inspection as all documentation relating to service users was kept in lockable cupboards or in a room that was kept locked at all times. The manager and staff were very aware of the need to hold information in confidence. The home also has clear policies in place relating to confidentiality. Some discussion took place in relation to the use of a daybook, which is where information is written down at the end of each shift about each service user. A recommendation is made to have information documented separately for each service user. (See recommendation)Chesham HousePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users are encouraged to become involved in activities within the community. Examples noted by the Inspector included working in a local crèche and attendance at courses at the local college. These activities are linked to the individual therapeutic programmes. Service users spoke enthusiastically at attending nights out at the local nightclub and being involved in the process of becoming more independent such as planning, purchasing and cooking their own meals. All relevant information is documented which includes any risk assessments and are decisions reached collectively.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? The service users who spoke to the inspector during the inspection expressed pleasure in the education and training that has been made available to them such as college courses, working at a local nursery and classes in textiles and Yoga. Appropriate information was recorded in different areas within the home such as individual plans and activity programme.Chesham HousePage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? As mentioned in previous standards, service users gain access to a number of different activities within the local community and information is recorded on service users files. The home is located close to the City of Norwich and easily accessible. A number of the service users have their own transport and have learnt to drive whilst residing at the home.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The home has a large art/activity room that also houses a computer with internet access for service users. There were a number of creative items on display that the service users had produced. There is a large garden with plants, a pond and a large grass area for outside activities. Residents are encouraged to participate in any suitable outside activities of their choice.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users are encouraged to maintain contact with family and friends. Records of family visits were seen and relatives are usually invited to attend review meetings. Equally there are some situations when family become involved in the therapeutic process such as attending Family Therapy appointments. Service users informed the inspector that they are able to have visitors in private if requested as there are many areas and rooms for private discussion.Chesham HousePage 17 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Clear guidance is in place to assist service users to prepare for the specific responsibilities of communal living as well as to prepare them for independent living. A good example of this is the well planned large kitchen area that is arranged in such a way to promote healthy eating in pleasant surroundings. Any restriction that is placed on the service users was clearly documented and are decisions that will be reached collaboratively with parties signing documentation.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The promotion of healthy eating is clearly at the forefront of the care and support offered at Chesham House. Menu planning meetings are held weekly with individual service users with emphasis on encouraging a varied well balanced diet. Clear records are maintained of the meals taken and these are taken into account when developing and revising the therapeutic care plans. Staff knowledge of the issues surrounding eating disorders and the importance of a well balanced diet is commended. The Inspectors were particularly impressed with the very pleasant kitchen and dining area being large, well furnished and an attractive comfortable place to cook, eat and socialise.Chesham HousePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? All service users are totally independent with their personal care and have the normal access to the range of GP and other health care services. The service users who spoke to the inspector said that staff were very supportive and understanding of their needs both physically and psychologically. They felt respected by the staff and that they trusted them to be able to share any difficulties that they may encounter. They considered that they had total control over their lives and were provided with the necessary support to make decisions whilst residing at the home. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 2X3 Key findings/Evidence Standard met? There was evidence at the home of appropriate documentation as well as observations and discussions that this standard is met. Service users said to the inspector that the staff at the home dont just make sure you are physically improving; they provide other support to help with your psychological needs as well. They have much more of an understanding about the illness and provide an all round approach. The inspector considers that these statements provided from service users are very complimentary and reassuring about the service.Chesham HousePage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? This standard was not fully inspected but due to a recommendation made at the last inspection some documentation was seen on the day of the inspection that this standard is being complied with. Currently all service users self-administer their medication and clear records were seen to assess to risk and tracking of the medication that is being received into the home. This standard will be assessed more thoroughly at the next inspection. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Chesham HousePage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X X X Standard met? 0Key findings/Evidence This standard was not assessed during this inspection.Chesham HousePage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? The home has a written policy and procedure in place regarding the protection of vulnerable adults. These are in line with the Norfolk Adult protection policies and procedures. A requirement made at the last inspection to have further information about other agency involvement and the expected response staff should take about possible allegations has been complied as this additional information is now incorporated within the document.Chesham HousePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 4 Key findings/Evidence Standard met? The premises are accessible, safe and well maintained both inside and out. There are a number of communal areas, which are well decorated and have quality furniture and fittings. The furnishings and décor of the home creates a homely and relaxing atmosphere, which is necessary for the service users at the home. The service users spoke highly of the home environment to the inspector during the inspection and that it meets their individual and collective needs.Chesham HousePage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence YES NO NO 6 0 0 0 Standard met? 3 6 00 0 0 0A number of the service users rooms were seen during the inspection with the agreement of the service users. It was clear that all the rooms were of a good size. They provided the service users with sufficient space and exceeded the size recommended in the standard. The service users were very happy with the accommodation.Chesham HousePage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? All the rooms seen were personalised and provided appropriate furniture to meet the individual needs of the service users. The furniture appeared of good quality and each service user had a lockable cupboard in the wardrobe of their room. The doors entering the rooms were not fitted with locks and discussions with the service users found this to be positive as they felt they were trusted and that they trusted each other and this contributed to the homely feel of the establishment.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? There are three bathrooms and one shower room, all with toilet facilities. There is an additional toilet on the ground floor. These provisions meet the assessed needs of the service users and provide the necessary privacy when completing their personal care needs.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 4 Key findings/Evidence Standard met? There are three lounge areas in the home furnished to a good standard. There is also a separate dining area and two other eating areas in the kitchen There is a well-equipped art room, which provides access to the computer and internet. A separate private therapy room is available which is used for other activities when required. There is a pleasant and welltended garden to the rear of the property with a small conservatory. It was evident from a tour of the premises that the home has an extensive number of rooms available for the service users to access.Chesham HousePage 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? During the tour of the premises all areas of the home were clean and hygienic and the facilities available to the service users was appropriate to meet their particular needs.Chesham HousePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The staff team are well trained and employ a number of different professionals to work in a multidisciplinary way. Therefore they can provide a wide range of support and therapy to meet the specialist needs of the service users.Chesham HousePage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXX3 Key findings/Evidence Standard met? The home had a number of staff on shift during the inspection, which was sufficient for the number of service users at the home. The staff team are well trained and competent to support the service users with specialist support as a number of staff have specialist training and qualification to meet the needs. The manager outlined to the inspector a detailed plan that is being undertaken for a percentage of the staff team to complete their NVQ. Documentation was not requested during this inspection to provide additional evidence due to the inspection being unannounced but will be required at the next inspection.Chesham HousePage 28 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Staff receive good support and advice from a range of professional and skilled personnel based at 153 Newmarket Road. All staff have a training file and mandatory training such as first aid, fire safety etc have been undertaken. Relevant in house training is also provided on such topics as eating disorders and depression. Senior staff attended workshops and conferences and the information is then shared with all other staff. New staff also undertake an in house induction programme and the current manager has gathered information about the induction and Foundation Training programmes that is issued by the National Training Organisation (TOPPS) to ensure that the in house training meets these national specifications. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Due to the nature of the service it was evident that staff receive regular support and supervision both on an individual basis and within a group. The staff team are able to access supervision externally on an individual basis if requested. The staff team have regular meetings and at shift changeover will also provide supportive times for the staff when required.Chesham HousePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO0 Key findings/Evidence Standard met? The current manager has submitted an application to the commission to be registered as the manager and is in the system to be processed. This standard will be assessed more thoroughly at the next inspection. However, it was evident from the discussions that the manager has extensive knowledge and experience to manage the home effectively. She demonstrated enthusiasm, motivation and belief in the purpose of the home.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? It was evident throughout the inspection that the ethos of the home is to promote a collaborative approach that includes all the stakeholders. Everyone who spoke to the inspector considered that they were very much included in all areas of their life within the home and felt that there was a positive and energised atmosphere. Information was clearly documented which further demonstrated the collaborative approach.Chesham HousePage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed during this inspection.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection.Chesham HousePage 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? This standard was partly assessed and a sample of records was seen such as fire certificates and mandatory staff training that has been undertaken. Staff receive an induction programme, which is being explored further by the manager to check that it is in line with the TOPPS specification. There was a clear log of accidents and incidents, which was seen on the day of the inspection.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed during this inspection.Chesham HousePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition The home is registered as a Care Home.ComplianceYESComments It was evident from the observation, view of documentation and records as well as discussions with the service users and staff that this is being complied.Condition Compliance The home is registered in the category of Mental Disorder. Comments It was evident throughout the inspection that this condition is being complied.YESCondition Compliance The home is registered to accommodate 6 service usersYESComments It was evident from the observation, view of documentation and records as well as discussions with the service users and staff there was no more than 6 service users residing at the home during the inspection.Condition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Chesham HouseMark Gower Roger HadinghamSignature Signature SignaturePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Chesham HousePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27th April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleChesham HousePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 14th June 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESChesham HousePage 36 Other: enter details here Chesham HousePage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Chesham HousePage 38 - 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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