Inspection on 04/03/08 for Chestnut House

This inspection was carried out on 4th March 2008.

CSCI found this care home to be providing an Adequate service.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chestnut House 05/02/09

Chestnut House 01/03/07

Chestnut House 25/01/06

Chestnut House 17/06/05

Chestnut House 22/09/04

Chestnut House 05/05/04

Similar services:

22 Sandown Road

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Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Chestnut House 141 Acklam Road Thornaby Stockton-on-Tees TS17 7JT Lead Inspector Jackie Herring Key Unannounced Inspection 4th March 2008 09:30 Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 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 House DS0000000005.V360737.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 House DS0000000005.V360737.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnut House Address 141 Acklam Road Thornaby Stockton-on-Tees TS17 7JT 01642 670581 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) val.bowman@mencap.org.uk www.mencap.org.uk Royal Mencap Society vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons shall not at any one time exceed 6 people with learning disabilities 1st March 2007 Date of last inspection Brief Description of the Service: Chestnut House is registered under the Care Standards Act 2000 with the Commission for Social Care Inspection as a care home providing care and accommodation for up to six adults who have a learning disability. The home is operated by the Mencap Homes Foundation for the Royal Mencap Society and is on the busy Acklam to Thornaby main road. The home is a large detached house retaining many or the original features, and is in keeping with the surrounding area. The building is indistinguishable from other houses in the neighbourhood. The home has six single bedrooms, none have an en-suite, but all service users have access to the communal bath/shower and toilet facilities. The weekly fees at Chestnut House could not be determined at the inspection. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced Key Inspection of Chestnut House; as such all of the key standards related to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two-inspection day by one inspector. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service and staff. Time was also spent in the home, observing interactions and generally finding out what Chestnut House was like for the people who live there and staff. Discussion also took place with the interim manager and proposed manager of the service. The interim manager, who had only been at the home a short while completed the Annual Quality Assurance Assessment (AQAA), the services selfassessment of how well they think they are meeting standards. Some of information has been reflected within the report to support the judgements made. Discussion took place with the interim Manager, proposed manager and Service Manager. All acknowledged there was the need for improvement and further development at Chestnut House. It was however clear from this inspection that the organisation are committed to making these improvements. What the service does well: Chestnut House provides a warm, friendly and caring environment for people to live. People who live there spoke of being happy and were very positive about the staff who provided their care. They are able to make choices and decisions about their daily lives. A member of staff said, “Each service user has choices, we sit down with them, through the keyworker system and discuss their plans with them”. People who live at Chestnut House said, “I am happy here and settle, the staff are very good, I feel well supported, they are approachable and I can talk to them about anything”. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 6 Staff clearly had developed very good relationships with the people who live at the home. Friendly interventions were observed throughout the inspection and there was much laughter. What has improved since the last inspection? What they could do better: A number of areas have been identified as in need of improvement. It was disappointing that the environmental improvements that had been identified at the last inspection have not yet been attended to. A bathroom, a shower room and a toilet are in need of redecoration. The ground floor bedroom needs some attention as there is a damp odour and this room needs a thorough spring clean. A number of carpets need to be cleaned or replaced and some furniture needs attention. The work that had commenced on updating people’s assessments, risk assessments and support plans needs to continue to ensure that these plans are current to peoples needs. More opportunities for personal growth and development need to be looked at. The medication system needs some additional information to enhance what is already in place and some recommendations have been made in regard to the storage. The home is in need of a permanent manager and for the management systems used by Mencap to be further established within the home. Staff when asked about what needed to improve said, “The home has been lacking some direction, Val (interim manager) is getting things back on course, she has been excellent”. Incidents that may effect the welfare and wellbeing of people who live at the home need to be fully recorded and all relevant agencies informed, with any required action being taken. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 7 The recruitment and induction of new staff should be reviewed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 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 House DS0000000005.V360737.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was looked at during this inspection. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they are assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA had been completed prior to this inspection and contained the following information. “We ensue that the needs of the service users are fully assessed before they receive any service”, “Consultation with the service users currently residing in the home is effective regarding people moving in/on. It also confirmed that assessment documentation is received from Social Services and that the service carry out their own assessment. Consultation with present people who use the service was described and then planned visits; overnight stays and review of progression of these visits take place. The importance of developing relationships was described. Two sets of care records were looked at. There had been no new admissions since the last inspection. At that time a clear assessment and admission process was described. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff and are able to make choices. However, records detailing how personal care is to be delivered and associated risks need to be reviewed and updated ensuring that individual support plans are representative of people’s current needs and risks. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Mencap have comprehensive assessment and care documentation, which lead to very detailed support plans for people living within their services. All of the people who live at the home have a range of information in place for them and this includes within the assessments twenty areas of need including selfadvocacy, behavioural and emotional needs, leisure, domestic skill and relationships. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 11 At the previous inspection, it had been identified that there was the need to ensure that the records of people who live at Chestnut House were up to date and current to their care needs. This was also identified within the organisation and detailed within the internal audit system. Discussion took place with the interim manager who confirmed that she was in the process of completing this but that there was still some way to go. It was agreed at this time, that a number of people’s records were not fully reflective of their needs and individual support plans continue to be in need of review and updating. Two of the plans were looked at, but it was agreed that the records would not be looked at in specific detail at this inspection as this had already been identified as an area in need of improvements and work was underway with it. The interim manager showed one of the files that had been updated and there was substantial information in place along with risk taking strategies. It is clear from the conversations that took place that people who live at Chestnut House are consulted about the support plans. A member of staff said, “Each service user has choices, we sit down with them, through the keyworker system and discuss their plans with them”. Informal observation throughout the inspection showed that the staff understand the rights of individuals and were seen to support people to make their own decisions and choices. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People are treated with respect. Where appropriate some people are involved in independent living arrangements, this could be developed further. People benefit from maintaining where possible personal relationships and have their right respected. Meals are provided to a satisfactory standard within a suitable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the five people who live at Chestnut House had done so for some time. It was confirmed that two of them continue to attend day facilities as college and are involved in such activities as cooking. Support workers who visit the home are involved in taking individual people out to community-based activities of their choice, whilst others people tend to spend time in the home. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 13 There was some discussion with staff and the thoughts were that whilst people who live at Chestnut House are settled and seem generally quite happy there are indications that they could be further supported to live more independent lives than they do already. It was confirmed that this would be looked at in more detail with the updating of the individual support plans and with the involvement of other agencies such as social workers and care managers. One of the people said, “I have been attending the day services for a substantial number of years and am now really ready to do something else”. All of the people who live at Chestnut House had recently been on holiday to Blackpool, which they enjoyed. Other holidays will be planned and these may be on a more individual basis. People also spoke of maintaining links with their family and having personal relationships. During discussion with people who live at the home and staff, it was confirmed that the meals and menu planning is fully consultative and menu planning meetings take place on a weekly basis. A member of staff said, “Service users are involved in menu planning, doing the shopping list, they can ideas from cookery books and some are involved in the actual cooking”. During tea on the second day of the inspection, people were looking at a cookery book to get some ideas for the following weeks meals. One of the people spoken to said, “I am happy here and settle, the staff are very good, I feel well supported, they are approachable and I can talk to them about anything”. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have their healthcare and personal care needs are met by staff who provide support in a sensitive and flexible manner. Medication systems and records are satisfactory and only staff who have received the appropriate training have any involvement with medication. Some additional development is needed which will strengthen this further. EVIDENCE: The AQAA detailed that life for the people who live at Chestnut House is flexible and people are able to make decisions about their daily lives. Time was spent during this inspection interacting with the people who live at Chestnut House and observing how they made decisions and lived their lives. It was clear that life is relaxed and flexible and people are able to decide how they spend their day. They were clearly were very comfortable and during informal conversations spoke positively about the staff team. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 15 The AQAA detailed that people who live at the home have access to NHS healthcare facilities they work together with other professionals, physiotherapists, speech therapists and occupation therapists. During discussion with the interim manager, it was identified that there is some work to do with individual, particularly when they will not attend appointments needed for or psychological interventions. The interim manager said that work is being done in this area and they are awaiting the involvement of the care manager. The medication system was looked at and there was discussion with the interim manager and a member of staff. It was confirmed that all staff are qualified to administer medication and have completed the required certificated training. The system for ordering medication was described. Medication assessments and care plans are also in place and in line with the work that is taking place on the individual support plans, these are also being updated. It is recommended that an up to date BNF be available on site. Where items are handwritten onto the Medication Administration Records, two staff are to sign for this and the quantities need to be included on the Medication Administration Record. It was recommended that staff responsible for the administration of medication undertake regular competency assessments. It was also identified that currently none of the people who live at Chestnut House self-medicate. This is an area that will be explored further within the update of the support plans and risk framework. In looking at the medication, there was a loose tablet in an envelope that had been there for some time, which one of the people takes out with them in the event it is needed. The system for managing this needs to be strengthened the medication should be reviewed. The room in which the medication is stored, whilst has been satisfactory is not the most conducive and the storage facilities could be improved upon. It is recommended in the event that the storage facility is changed that more secure arrangements are put in place. The temperature of the room in which the medication is currently stored should be monitored to make sure that it is not too hot. The internal audit indicated that there had been some incidents involving the administration and/or storage of medication. Further information has been requested. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 22 & 23 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People who live at the home have access to the complaints procedure different formats. Staff have had training around safeguarding adults to ensure protection of people who live at the home. It is unclear if all matters have been appropriately recording, as such there may be the need to strengthen this further for additional protection. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed that, “Each service user is given a copy of the complaints procedure, which includes the stages, and timescales”. It also detailed that this is discussed at service user meeting and that the procedure is available in other accessible formats, such as CD. The interim manager confirmed that there was a complaints book but that there was very little information contained within in. It was however confirmed that a concern raised by one of the people who live at the home had been referred to adult protection. The AQAA also shows that there has been one complaint received in the past 12 months and one adult protection concern. It was unclear from the information shared during the inspection if all matters that were potential incidents involving people who live at the home had been Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 17 fully investigated by the appropriate people. It was agreed that further information would be forwarded to the inspector. Staff during discussion confirmed that they were aware of the complaints and Protection of Vulnerable Adults procedures. The AQAA also detailed that staff receive this training as part of their induction and continuous professional development. A member of staff said, “The service users can and will come to staff with any concerns and worries”. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 24, 27 and 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The environment is generally appropriate in terms of size and layout to the specific needs of the people who live there. People are able to personalise their bedrooms and the home is warm and comfortable. A number of improvements are needed to the environment to enhance the quality of life of people living at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Chestnut House in places is very warm and homely. The atmosphere of the home was domestic in nature, friendly and created a family environment. It is disappointing that no improvements have been made to the environment since the last inspection where improvements were clearly identified as needed. It is not acceptable for people to have to live with undecorated bathing facilities for more than twelve months. This bathroom has had the Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 19 wallpaper stripped off and there is no light shade, the flooring may also need replacing. Redecoration is needed to a number of areas. The ground floor shower room needs attention as does the ground floor bedroom, in which there is clearly some damp and was not a pleasing environment at all. The dining room needs to have the carpet cleaned or possibly replaced, as does the corridor. The upstairs shower room also needs some redecoration, pipes need to be boxed in and the mildew needs attention. The arrangements for spring cleaning also need to be looked at as in one of the bedrooms visited it is clear that this had not happened for some time. Care is also needed with the use of electrical extension cables; it may be that additional sockets are needed in people’s bedrooms. Some furniture is in need of repair and/or replacement such as the wall unit within the dining room as this had a door was missing. A number of keypads had been fitted to doors within the home, this was for a specific reason to promote a person’s safety, if these are no longer needed and should be removed. A number of boxes were observed which contain archive materials; these are stored in the laundry area and also the staff sleepover room. It was identified that this needs to be attended to for a number of different reasons. The storage within the laundry may not comply with data protection and there is the potential increase fire risk with having so much paper stored. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 32, 33, 34, 35 and 36 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are very satisfied with the care they receive. Recruitment procedures are generally good, however some strengthening of this is needed to ensure that people are protected. The manager recognises the need to ensure all staff are well trained although records to support this need further development. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There has been some change in the staff team over the past twelve months. The files of two new support workers were looked at. In the main they contained the required information such as application form and evidence of Criminal Records Bureau checks. Care is however needed as on both of the files looked at one of the references was not from their most recent employer. In one of the files, there was no evidence of induction. It was thought that there might have been a delay in this due to the changes in management. There is also the need to ensure that copies of qualifications and certificates are obtained. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 21 Staff arrangements were discussed and it was explained that all staff are support workers and anyone of them are able to lead the shift. The person who leads the shift is determined by who does the sleepover. Usually there are two support workers on duty during the day, however there is some flexibility within the staff to allow for evening activities. A member of staff said, “Definitely now have sufficient staff to met the needs of the service users and there is flexibility built in, some additional staff”. The training plan was not very detailed and records did not fully support or detail the training that has or is taking place. The interim manager agreed that this needed to have more detail. Staff supervision has not been taking place at the required intervals. There is evidence of this taking place in January and February and some evidence in 2007, but not as frequently as needed. The AQAA details that currently 50 of the current staff are qualified to NVQ Level 2. Staff clearly had developed very good relationships with the people who live at the home. Friendly interventions were observed throughout the inspection and there was much laughter. People who live at the home were positive about the staff team and described them as friendly and approachable. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 37, 39 and 42 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. There is currently no registered manager in post. A number of areas require further development to ensure good management systems are in place and that health, safety and welfare is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There has been no registered manager in post for approximately six months. In the meantime a manager was appointed but no application was made to register them with CSCI, this person is no longer in post. There is now an interim manager in post who has been in post for a short time and is very clear about what needs to be achieved within the home. A permanent manager has been appointed and will be in post in the near future. The home Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 23 clearly needs a permanent manager to bring about the stability that is needed to the people who live at Chestnut House, the staff and to ensure that the systems and procedures developed by Mencap are fully followed and in place. Staff when asked about what needed to improve said, “The home has been lacking some direction, Val (interim manager) is getting things back on course, she has been excellent”. There was some discussion with the interim manager and proposed manager; they were very clear about the developments that were needed within Chestnut House. There was a real sense of commitment and enthusiasm about these developments and how to improve the service for the benefit of all. Some concerns have been raised about the management of the home. A number of regulation 37 notifications have not been received and were not available within the home. Correspondence about the change in managers had not always been received by CSCI but the most recent changes have been notified to us. Through discussion with the interim manager about the management of people’s personal allowances, it had been identified that the system needed to be strengthened as receipts were not always obtained and the arrangements for paying for the support staff mileage was not happening in the agreed way. It was unclear at this time what was in place in the way of quality assurance. The interim manager did say that Mencap had quality assurance systems and an internal service audit had been carried out, however there was no corresponding action plan or target dates. The AQAA detailed information regarding maintenance and equipment. A sample of records was looked at and showed that Portable Appliance Tests and Gas serving was up to date. The weekly fire test records were looked at and showed that these had not always been tested weekly, although steps have now been taken to ensure this happens. During the second inspection day, the fire alarm was activated, everyone knew exactly what to do and carried out a safe and planned evacuation from the home, with staff then determining the safety of all to return. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 24 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 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 (2) Requirement The work that has commenced on updating the individual people’s support plans must be completed ensuring that assessment and plans are up to date and representative of people’s current needs and aspirations. The medication systems must be reviewed to ensure that is safe, with appropriate storage and good supporting records. Any handwritten items of the MAR sheet must have two signatures. An up to date BNF is needed. The temperature of the room must be monitored to ensure that it is not too hot. Any incidents involving people’s medication must be reported via Regulation 37 notifications. The medication for one person living at the home must be reviewed and appropriate systems are needed for taking Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 26 Timescale for action 30/05/08 2. YA20 13 30/04/08 medication out of the home. 3. YA23 13/37 Incidents involving the welfare and wellbeing of people living in the home must be reported to the appropriate agencies and information detailing this must be available within the home with supporting documentation. The planned maintenance and redecoration must be carried out: The stair banister with peeling paintwork must be redecorated. The dining room and corridor carpet must be cleaned or replaced. The damp problem in the ground floor bedroom must be addressed. The keypad locks if no longer needed to promote safety must be removed from the doors. All of this will enhance the environment for the people who live there. The upstairs shower room must be redecorated. The flooring must be replaced as must the light shade and the bathroom must be redecorated. (These requirements have not been action since the last inspection) The upstairs bathroom must be redecorated. The ground floor toilet must be redecorated. All of this will enhance the environment for the people who live there. Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 27 18/03/08 4. YA24 23 (2) 30/05/08 4. YA27 23 (2) 30/05/08 5. YA34 19 6. YA35 18 7. YA37 8 8. YA39 37 9. YA42 YA41 13 The staff recruitment records must have all of the information as detailed within Schedule 2. This includes reference from most recent employer and copies of people’s qualifications and certificates. This will ensure that people who live at the home are protected by good procedures. All new staff must receive induction. Those staff who are not qualified to NVQ Level 2 must complete the Skills for Care Common Foundation Standards. This will ensure that staff have the information needed to support people living at the home and to meet their health and safety needs. The management arrangements must be formalised and the stated action must be taken for there to be a manager registered with CSCI. This will ensure leadership and management of the home for all. The quality assurance systems must be implemented fully within the home. Incidents that effect the welfare, well being and safety of people must be notified to CSCI via Regulation 37 notifications. Weekly fire checks must take place within the home and be recorded. The current amount of archiving material must be looked at, ensuring that safe amounts of paper material are stored at the home. The storage of this material must comply with data protection. 01/05/08 01/05/08 30/06/08 30/04/08 30/04/08 Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations The work that has commenced on updating risk management arrangements should continue and people should be enabled to take risks that have been fully assessed and planned for. More opportunities should be developed for people to be involved in other activities that will enhance their lifestyle. The work that has commenced on ensuring that people’s health care needs are being met should continue. Consideration should be given to developing ongoing competency assessment for the administration of medication. Consideration should be given to improving the storage arrangements for medication. Consideration should be given, where appropriate for people to manage their own medication. There should be an effective system in place for the housekeeping arrangements particularly in relation to individual bedrooms. A number of areas including carpets need more thorough cleaning. Staff should receive supervision six times per year. There should be an up to date programme that details the training in place for staff. Staff need to undertake training that gives them the knowledge and skill to meet the needs of the people they are caring for. 2. 3. 4. YA12 YA19 YA20 5. YA24 6. 7. YA36 YA42 Chestnut House DS0000000005.V360737.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 House DS0000000005.V360737.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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