Inspection on 24/01/06 for Chestnut Grange Care Home

This inspection was carried out on 24th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chestnut Grange Care Home 26/07/06

Chestnut Grange Care Home 06/05/05

Chestnut Grange Care Home 29/11/04

Chestnut Grange Care Home 07/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Chestnut Grange Care Home Main Street Weston Nottinghamshire NG23 6ST Lead Inspector Jayne Hilton Unannounced Inspection 9:45 24 January 2006 th Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 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 Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 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. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chestnut Grange Care Home Address Main Street Weston Nottinghamshire NG23 6ST 01636 821 438 01636 822 642 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) Voyage Limited Brenda Rolfe Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users shall be within category LD Date of last inspection 6th May 2005 Brief Description of the Service: Chestnut Grange is a large detached property in a very rural area. It is home for 10 service users with a learning disability and additional specific needs. There is an enclosed garden to the rear and a smaller garden to the front of the property, there is also ample parking to the front of the property. The home provides transport for the service users. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulation Inspector Jayne Hilton carried out the inspection on Tuesday 24th January 2006 from 9.45am until 12.15pm. The focus of the inspection was to assess if the requirements and recommendations set at the previous inspection had been met and to assess any key standards remaining over the inspection year. The registered manager was not available for the visit and therefore the Team Leader and staff on duty assisted with the inspection. Most of the service users were out for the duration of the inspection however; the inspector was able to engage in communication with four service users at intervals as part of their daily lifestyle. Observations were made of staff interactions and in dealing with a service user who became distressed/challenging. A part tour of the building took place and the other methodology used for the inspection incorporated the Statement of Purpose and Service User Guide, complaints records, medication management, the examination of three support plans, examination of policies and procedures, quality audits, health and safety records etc and food stocks. What the service does well: Service users individual needs and aspirations are assessed and prospective service users know that the home will meet their needs and aspirations. They have the information they need to make an informed choice about where they live. Multi disciplinary involvement and support contributes to the specialised development plans. Service users at Chestnut Grange know their assessed and changing needs, personal goals and responsible risk taking, are reflected in their individual plan, they are consulted and encouraged to participate and make decisions about their lives with assistance as needed. Service users are encouraged to strive for personal goals and service users have made significant progress and achievement despite having complex needs. Service users lifestyles are well balanced with personal development, education, leisure and daily living responsibilities and routines, which promote community links and inclusion. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 6 The management of the complex needs of service users is balanced with good promotion of individual rights. Service users can be confident that information about them is handled appropriately and confidences kept. There is an effective complaints procedure which service users are clear about. Service users are protected from abuse, neglect and self-harm. Service users benefit from a well run home that generally promotes and protects their health and safety with good record keeping. Service users rights and best interests are generally safeguarded by the homes policies and procedures and service users are confident their views underpin all self-monitoring review and development of the home. Service users are offered a healthy diet and enjoy their meals and mealtimes. Service users are provided with flexible personal support to maximise privacy, dignity, independence and control over their lives. Systems are in place for ensuring the healthcare needs of service users are met. The systems in place for the management of medication was satisfactory The wishes of service users at the end of life are obtained. Service users live in a homely, clean, comfortable and safe environment. Personal and communal space meets the needs of individuals residing in the home. What has improved since the last inspection? Issue around terms of address used by staff to service users has been reviewed and addressed. The systems in place for ensuring the healthcare needs of service users have been improved. The systems in place for the management of medication have been improved. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 7 Service users finances are now checked and audited to protect, service users, manager and staff. 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. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 8 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 Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 9 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): 1,2,3,5 Service users individual needs and aspirations are assessed and prospective service users know that the home will meet their needs and aspirations. They have the information they need to make an informed choice about where they live. Multi disciplinary involvement and support contributes to the specialised development plans. Service users had an individual written statement of terms and conditions. EVIDENCE: A comprehensive Statement of purpose and service user guide is available and in sign/symbol formats and on hard disc. Three care/development plans were examined, each contained a detailed assessment, which included clear information about any specific or specialised needs. Terms and conditions of residence were seen and signed by the individual or their representatives. The document contains a furniture list of what the home provides in service users rooms. The service users at Chestnut Grange have various specialist needs, including Prada Willis Syndrome and Pica syndrome. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 10 Development plans were well detailed and informed staff of how service users needs will be met. There was evidence that development plans are supported by, psychiatrists, psychologists, social workers etc. A review for one service user was held on the day of the inspection. A service user had written a statement of his needs within the development plans. Development plans include short and long term objectives. The achievements of service users were very clear and a service user praised the manager and staff for supporting him to achieve his particular goals. Pictures and symbols were observed within development plans and around the home. Staff were observed to communicate in various methods, including the use of makaton. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 11 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): 6,7.8,9,10 Service users at Chestnut Grange know their assessed and changing needs, personal goals and responsible risk taking, are reflected in their individual plan, they are consulted and encouraged to participate and make decisions about their lives with assistance as needed. Service users can be confident that information about them is handled appropriately and confidences kept. EVIDENCE: Three development plans were inspected, all were detailed and provided clear guidance for staff and are designed to identify service users needs and to establish and monitor service users short and long term needs. Weekly programmes for activities are included. Key values are incorporated within the package with aims and the philosophy of care to increase the level of independence for service users. The service users have accompanying challenging behaviours and therefore development plans are structured with the oversight of other specialist professionals in order for staff to assist the service users to manage these behaviours. Development plans covered the holistic needs of service users. The participation of service users, was evidenced by, personal statements or signatures. Resident meetings are held and there is a key worker system. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 12 Observations of staff supporting a service user who was distressed and presenting a challenge to the service were conducive with the individuals support plan. Risk assessments were evident and deemed appropriate by the inspector. All were reviewed on a six monthly basis. Within the necessary structures of the development plans service users are offered choice and encouraged to make decisions within any limitations set. Contracts for behaviour plans are used and those service users spoken with were aware of what these were. Staff members were observed reminding service users and interacting in a professional but non-oppressive approach. Contracts for behaviour programmes are signed by the individual service user. A buzzer alarm is set up within the office, which indicates when a service users bedroom door is accessed. The reasons for this are documented and the inspector is satisfied that this is in place in the best interests of service users and is consistent with the purpose of the service and the homes duties and responsibilities. Service users were observed to communicate freely and were smiling. Where service users develop increasing frailty or reach 65 years, development plans address this to ensure that the holistic needs of the service users are maintained and met. Service users records are stored securely, in the manager’s office, Staff was observed gaining access as required. A policy for confidentiality was accessible for staff and the topic was discussed with a staff member. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 13 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): 11,12,13,14,15,16,17 Service users are encouraged to strive for personal goals and service users have made significant progress and achievement despite having complex needs. Service users lifestyle’s, are well balanced with personal development, education, leisure and daily living responsibilities and routines, which promote community links and inclusion. Service users have appropriate family and personal relationships, however there was no evidence to support a judgement that service users have appropriate support to engage in sexual relationships or in their expression of sexuality. The management of the complex needs of service users is balanced with good promotion of individual rights. Service users are offered a healthy diet and enjoy their meals and mealtimes. EVIDENCE: Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 14 Service users continue to have varied daytime occupations and activities, which range from college placements, birds of prey centre, independent living skills support and training, money management, numeric and leisure pursuits. A service user went shopping with a member of staff to the local town on the day of the inspection and another informed the inspector it was his birthday and would be having a tea party later. Regular trips out are arranged and many photographs of parties, events and trips were seen. Holiday plans were underway, two service users have booked a break at Louth. A drama group is to be set up shortly. The home has its own minibus, and service users may use public transport if able. Service users reported that holidays are arranged and that birthdays are celebrated with parties and buffets. According to the service users spoken with, there is always plenty to do and that they go out and about on trips. Staff knock on service users bedroom doors before entering, give mail unopened and respect service users privacy. Service users who are able have keys to their rooms, a service user was observed using a key to gain access, and other service users have access to their key with supervision. The service users preferred term of address was noted in the development plan, the manager has undertaken discussion work with service users and staff to ensure that service users are addressed respectfully and appropriately A Charter of Rights Statement was observed in the development plans examined. There was lots of staff/service users interaction observed throughout the day of the inspection. Senior staff particularly demonstrated skill and knowledge of the individual’s needs and programme. Service users spoken with informed the inspector that they have responsibilities for housekeeping tasks, which was supported by evidence in development plans and individual contracts. Food is stored away from the main building as part of the structure for assisting service users to manage their eating disorders. Food stocks were observed to be ample, however some items of opened food such as processed meats, cheese, jars of sauces etc had not been date labelled when opened. There was also several items out of date; these were yeast, gravy stock cubes, herbs, spices etc. Several opened packets of pasta, flour, icing sugar were vulnerable and should be stored in sealed containers to prevent contamination. A system needs to be set up to ensure stock check Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 15 and food rotation. Staff confirmed aprons were provided and that both service users and staff wear these when preparing food. Service users were observed to be moving freely in the home and gardens, within the limitation of the buzzer/alarm already discussed in the report. There was evidence that service users are supported to maintain contact with relatives and one service user has a friend who resides in another group home and they mutually visit each other for meals etc. The confidentiality policy discusses consent for sexual relationships, however staff spoken with was unsure of the homes philosophy in general about sexuality and relationships. It is recommended that the manager discuss the topic with staff and confirm with the inspector that there is an appropriate policy in place for sexuality and relationships that gives clear guidance for staff and service users. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 16 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): 18-21 Service users are provided with flexible personal support to maximise privacy, dignity, independence and control over their lives. Systems are in place for ensuring the healthcare needs of service users are met. The systems in place for the management of medication was satisfactory The wishes of service users at the end of life are obtained. EVIDENCE: The development plans contained clear information about the personal support and specific healthcare needs of service users. Service users informed the inspector that they choose their own clothes when getting up in a morning and confirmed staff support for personal care as identified within the personal development plan. Service users were observed, to be dressed in varying styles, which reflected their personality. The bedrooms inspected were also personalised. Support from specialist professionals is documented in the development plan. Where service users present challenging behaviour this is covered within development plans and charts. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 17 Chiropody check records are kept in the care plan, as are, annual well person checks, smear tests etc A staff member informed the inspector, that those, staff who administer medication undertake ‘distance learning’ training in medicines management and that the manager undertakes competency assessments periodically. The keys for the medicine storage room were kept separate to other house keys and these are handed over between senior staff. A spot check on medication appeared satisfactory. Photographs are used on medication charts. Two staff signs the medication records and service users where appropriate. The policy for drug errors informing staff of contact numbers and procedures was clearly visible and reminded staff to report any incidents of drug errors to CSCI, as required by regulation 37. The Inspector was informed there were no service users who were self medicating currently. Development plans included detailed information about medication and included details any medication reviews and changes in medication. Where suitable, service users may wish to work towards a goal of achieving independence in managing their own medication and this should be part of the medication profile also Where service users are prescribed ‘as required’ medication [PRN] for challenging behaviours, this is only administered after authorisation from a senior manager in the organisation, this system of good practice ensures that PRN medication is only dispensed to service users as a last resort in managing behaviour or at the service users request. The British National Formulary was in date. The Inspector gave the manager details of the Royal Pharmaceutical Society guidance on medicine administration in care homes in order for policies in medicines management policies and procedures to be further developed. [The policy file could not be located and therefore this action was not followed up at this visit] The wishes of service users at the end of their life are documented within development plans. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 18 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): 22,23 There is an effective complaints procedure which service users are clear about. Service users are protected from abuse, neglect and self-harm. EVIDENCE: There is an effective complaints procedure which service users are clear about as they clearly use it. There was one complaint logged since the last inspection in May 2005. This was dealt with appropriately. CSCI have not received any complaints about the home. A copy of the complaints procedure had been issued to those service users whose personal files were examined. The policy states that all complaints will be responded to within 5 days. Staff interviewed were aware of the complaints policy and whistle blowing policies should there be a reason to express concerns or challenge about other staff members practice. Staff confirmed that they had undertaken adult protection training. Service users spoken with said they felt safe. Safeguarding Adults procedures have been implemented by the manager in the last few months and there are no concerns identified in relation to the practices in the home. Policies are in place for dealing with verbal and physical aggression and all incidents were fully documented. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 19 Service users cash records were not examined at this visit, although staff were observed using the system. The manager checks the records monthly and signs that they have been checked and a representative from Voyage also audits the financial records periodically. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 20 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): 24-30 Service users live in a homely, clean, comfortable and safe environment. Personal and communal space meets the needs of individuals residing in the home. EVIDENCE: Chestnut Grange is a large detached property, which is in keeping with the local community. A tour of the building was undertaken at the inspection. Furnishings and fittings were in good order and were domestic and homely. New furniture has been purchased since the last inspection. There is provision for the staff of a suitable sleep-in room and the manager with a large office. The kitchen was large and the equipment appeared adequate. The activity room, dining area and large lounge are nicely decorated and are equipped with suitable furniture, The activity area provides a very pleasant environment and an alternative room to be used if relatives want to meet with service users in a room other than their bedroom. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 21 There are large enclosed gardens with seating and a gazebo. Two service users bedrooms were examined. All bedrooms examined were furnished and equipped appropriately and personalised by the individual. Toilet and bathroom facilities were sufficient, all were clean, had privacy locks and adequate ventilation. The laundry area was inspected and appeared to meet the standard. The home was very clean and free from offensive odours on the day of the inspection. All service users residing in the home are mobile apart from one service user requiring a wheelchair for outside long distances. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 22 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 Service users are supported and protected by the homes recruitment policy and practices. EVIDENCE: These standards were not assessed at this inspection apart from standard 34, action has been taken in relation to the visiting hairdresser, who is accompanied by a staff member at all times. Standard 34 was fully assessed at the previous visit. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 23 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): 37, 39, 40, 41,42 Service users benefit from a well run home that generally promotes and protects their health and safety with good record keeping. Service users rights and best interests are generally safeguarded by the homes policies and procedures and service users are confident their views underpin all self-monitoring review and development of the home. There are identified issues around surface temperatures of radiators, water temperatures and food safety, which must be addressed to ensure the safety of service users. EVIDENCE: A staff member commented that Chestnut Grange is successful as the staff are consistent in approach and support each other. The manager is now registered with CSCI. Quality assurance systems are in place in many forms, regular auditing take place and service users questionnaires were seen whereby service users spend Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 24 one to one time with the manager. A self-advocacy action pack is used by the home alongside resident meetings and a copy of the Quality Tree folder was observed in the home. The last date observed of the one to one time of service users was July 05, so it recommended that this be brought up to date. Policies and procedures for day-to-day support practices for service users were not located and this should be available for staff use. A sample of records was examined including service users information fire safety records, water outlet temperature checks, and complaints. Most have been covered in the context of other standards, however the water temperature records did not correlate with sample temperatures taken on the day, which exceeded 43 degrees. Action must be taken to ensure water outlet temperatures are regulated to no higher than 43 degrees. Health and safety practices in the home appear to be well managed, evidence was in records of kitchen records, evidence of gloves and liquid soaps, a service user confirmed that staff, wear protective clothing when attending to personal care and that he feels safety is protected. The health and safety poster and policies were satisfactory. Window restrictors are fitted throughout, some radiators were covered but others which were priority areas such as in bathrooms and adjacent to chairs in bedrooms were not. Radiators felt hot and therefore it is imperative that further work is completed. The surface temperatures of radiators present a significant risk to service users, particularly those with complex needs and epilepsy. Where service users prefer rugs in their bedrooms, risk assessments were included in their personal files. The lounge carpet was rippling/creasing in places [possibly due to cleaning and shrinking] Staff should be vigilant to ensure this does not become a trip hazard. There are some food safety issues to address [see standard 15] Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 4 4 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Chestnut Grange Care Home Score 3 4 3 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 2 3 2 X DS0000008754.V269534.R01.S.doc Version 5.0 Page 26 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 YA42 Regulation 12,13,16 Requirement Timescale for action 30/03/06 2 YA17YA42 12,13,16 3 YA42 12, 13, 16,23 Ensure that the surface temperatures of radiators are risk assessed and covers fitted to priority areas. Ongoing previous timescale not fully met 6/08/05 Ensure systems are in place 30/03/06 regarding food safety practices, in relation to stock rotation of food, date labelling and storage of packet items. Ensure water outlet 30/03/05 temperatures are regulated not to exceed 43 degrees. 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 YA15 YA17 Good Practice Recommendations Ensure there is a policy in place for supporting service users with sexuality and relationships and ensure all staff are aware of the homes philosophy in relation to this. Provide sealable containers for packets of pasta, flour, icing sugars etc. DS0000008754.V269534.R01.S.doc Version 5.0 Page 27 Chestnut Grange Care Home 3 4 5 6 YA17 YA39 YA40 YA42 Delegate the responsibility of stock rotation of food items to a named individual. The manager should ensure service user surveys [1:1] are up to date and current. Ensure staff have access to the policy file for service user daily support topics [and that policies for medication management are available for inspection]. Monitor the lounge rug to ensure it does not become a trip hazard. Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Chestnut Grange Care Home DS0000008754.V269534.R01.S.doc Version 5.0 Page 29 - 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!