Inspection on 04/09/07 for Chestnut House Care Home

This inspection was carried out on 4th September 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Chestnut House Care Home 14/02/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Chestnut House Care Home 69 Crumpsall Lane Crumpsall Manchester M8 5SR Lead Inspector John Oliver Unannounced Inspection 10:00 4 September 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnut House Care Home Address 69 Crumpsall Lane Crumpsall Manchester M8 5SR 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) 0161 721 4949 Beech House Care Homes Limited Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 19 people aged 65 or over (OP) who require personal care only by reason of old age. 14th February 2007 Date of last inspection Brief Description of the Service: Chestnut House is a care home providing personal care and accommodation for up to 19 older people and is owned by Beech House Care Homes Limited. No nursing care is provided. The home is situated in the Crumpsall area of Manchester. It is close to local shop and bus routes. However, local shops are not easily reached by residents, as a busy main road has to be crossed in order to access them. The home is a three storey building set within its own grounds. The garden is well maintained and easily accessible. Off road parking is available at the front of the building. There are 15 single bedrooms and 2 shared bedrooms. The rooms are not ensuite, however there are adequate toilet and bathing facilities available. There is a passenger lift to enable access to the first floor. The owners use the third floor as private accommodation. At the time of this inspection visit building work was in progress to convert shared rooms into single rooms with en-suite facilities. At the time of the inspection site visit, weekly fees averaged £373.54 and additional charges are made for hairdressing, private chiropody, newspapers, dry cleaning, some activities and the use of the telephone. Cost of transport such as private hire vehicles is not included in the weekly fee. Some charges may be made for escorting residents to private appointments but this is by arrangement with the management of the home. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection site visit took place over one and a half days and involved gathering lots of information about how well the home was meeting the National Minimum Standards. This included the manager of the home filling in a questionnaire about the home before the visit took place. This questionnaire is called an Annual Quality Assurance Assessment (AQAA) and the type of information asked for in this helps us to see what the management of the home think about the service they are providing. During the visit, lots of information about the way the home was run was gathered and time was taken talking with some residents, the manager, the owners and the staff team about the day-to-day care and what living in the home was like for the residents. Other information was also used to produce this report. This included information held by the Commission about any events that had taken place in the home that may have affected residents. What the service does well: On entering the home the atmosphere was found to be warm, relaxed and friendly. Residents were seen to be walking around the home and enjoying each other’s company. Comments included “We are looked after well” and “Staff are good”. The manager and staff of the home were good at making sure residents’ health was taken care of in the most appropriate ways. If other health care workers are needed, such as district nurses, this service was requested. The owners were continuing to make improvements to the environment so that residents and staff would have a more comfortable place in which to live and work. A number of written compliments had been received from relatives of people who were or had been living in the home. One recently received card stated, “To all the wonderful staff at Chestnut House. I want to say a big thank you from the family for all the love and care you gave to…during the time…lived with you”. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to all prospective residents and their family/relatives to help them make a decision about coming to live in the home. Resident’s needs are fully assessed before coming to live in the home. EVIDENCE: The Statement of Purpose and Service User Guide had both been updated with relevant information. Discussion with the manager confirmed that should it be requested both documents could be provided in large print versions. At the time of this inspection visit the manager was in the process of providing each resident with a copy of both documents. No new residents had been admitted to the home on a permanent basis since the last inspection visit in February 2007. However, there had been a recent admission/discharge for a person on a short stay in the home. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 9 Examination of the file demonstrated that all pre-admission paper work including a full assessment of need and a care plan had been provided by the placing authority. The manager of the home had also visited the individual and carried out an assessment to ensure that the home could meet any assessed needs. It is recommended that the manager confirm, in writing, following an assessment that the home can/cannot meet the assessed needs of the individual. The manager confirmed that intermediate care services were not offered. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports people to maintain their personal and healthcare in the way they prefer. Improvements are needed in the management of medication. EVIDENCE: Each resident living in the home had an individual plan of care and at the time of this visit the manager was in the process of reviewing and updating both the care plan and risk assessment formats used. No new residents had been admitted to the home since the last inspection visit in February 2007 and the file of one resident was randomly selected to be examined and was found to contain a good deal of information relating to the person including background information that informs staff of the things that are particularly important to the individual. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 11 The care plans for this particular resident included one relating to sight and one relating to washing/bathing/dressing. The care plan relating to sight stated that “(The resident) needs to see the optician at least once a year. Senior to ensure that this if followed up”. The care plan had been reviewed on a monthly basis, the last time being 02/08/07. The resident last saw the optician on 21/08/06 over 12 months ago – but this was not picked up during a review of the care plan. Advice needs to be taken from the optician on the recommended frequency of sight tests for this person. The other care plan stated that “2 carers to assist…. with all aspects of personal hygiene….” More information should be detailed to provide staff with clear details about how that assistance should be offered. Lack of such information could place the resident at risk of inappropriate support/assistance being given. One risk assessment in place stated exactly the same as the care plan – “2 carers to assist… with all aspects of personal hygiene…” This information does not identify the actual risk when this care was being given or how risks were to be managed. Lack of such information could place the residents’ health at risk. The resident and/or their representative had not signed the care plans or related documentation. It is important that this is done wherever possible to clearly demonstrate that the resident has fully participated in the development of their care package. This particular resident was suffering with pressure sores due to diminishing mobility and was being treated by the District Nursing service and records demonstrated that weekly pressure area checks were taking place. Evidence was also available to demonstrate that other healthcare professionals such as GPs had visited and good information was recorded about these visits. A number of written compliments had been received from relatives of people who were or had been living in the home. One recently received card stated: “To all the wonderful staff at Chestnut House. I want to say a big thank you from the family for all the love and care you gave to…during the time…lived with you. ….. could be difficult at times but you always treated her as the ‘unique’ individual she was, allowing her to get up late and eat at her own time. It was reassuring to us that she was safe, warm, fed and had company, plus a window to watch out of!” Only senior staff in the home had responsibility for administering medication and the manager had recently changed their supplying pharmacy. Although all staff had received training in medication administration the new supplying pharmacist was arranging to ‘re-train’ all staff with this responsibility. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 12 Medication was stored in a locked medication room. This room also served as a treatment room for district nurses to use and appropriate hand washing facilities were available. An appropriate medication refrigerator was available for the storage of any medication that may need to be kept at specific temperatures. A monitored dosage system is used to administer medication in the home and a new medication trolley had been supplied in which to store this. Medication administration records were in place and all have a front sheet containing a photograph of the resident to aid identification. The balances of medication to be given ‘as and when required’ such as Paracetamol were difficult to check. Where this type of medication indicated one or two tablets to be given, no indication was made of how many tablets had been administered at any one time. No remaining balance was recorded. This meant that an accurate ‘audit trail’ of such medication could not be maintained. This could place residents at risk from errors occurring in the administration of such medication. One resident had been prescribed Perindopril with administration instructions of ‘take 30 minutes to 1 hour before food’. This medication was not being given as prescribed, as it was included with medication to be given at breakfast time. This could make the medication ineffective and could place the resident’s health at risk. One resident spoken to about medication said, “I get my tablets – I have lots”. Observation of staff interacting with residents throughout the visit demonstrated that the privacy and dignity of residents was respected. Privacy locks were available on all toilets and bathroom doors and each bedroom had a lock that could be overridden in an emergency. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were encouraged and supported to exercise choice in their daily routines in relation to lifestyle and activities and to maintain contact with their relatives. EVIDENCE: Since the last inspection, activities for the residents had greatly improved and two members of the care staff team were dedicated to further improving the availability of various activities. At the time of this visit they were in the process of gathering information from residents about their interests and things that they would like to do. It was also discussed with the manager about the need to organise some type of activities for those residents who may be more mentally frail in order that their social and emotional needs can be met in the most appropriate way. On the day of this inspection visit residents were seen enjoying a game of indoor skittles and some of the ladies were also enjoying a ‘pampering session’ where they were having their nails painted. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 14 Discussion with the manager confirmed that no restrictions were placed on visitors to the home and examination of the visitors book clearly demonstrated that visits to the home by relatives and friends was fairly frequent. The manager had identified an Advocacy service in the Manchester area that was prepared to visit any resident who had no one to act on their behalf and on the day of this inspection visit someone from this service came to see a resident in the home. Feedback from residents spoken to was generally positive about the food served in the home and comments included, “You get choice – something different every day” and “ I’ve had chicken for my dinner – it was nice”. Menus are planned using a four weekly menu and a main meal was observed being served during the visit. This meal consisted of chicken casserole, mashed potatoes and various fresh vegetables. This meal was served hot, looked appetising and was nicely presented. Discussion with the cook confirmed that all residents are offered a choice of main meal on a daily basis and written records were seen to confirm this. Specialist diets could be provided for and the cook confirmed that the manager and senior staff keep her informed of any relevant medical information regarding individual residents so that she can plan suitable menus to meet any specific dietary requirements. Food stocks were plentiful and appropriate records were kept of fridge and freezer temperatures. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any concerns and to protect residents from neglect and abuse. EVIDENCE: A complaints procedure was in place, which was displayed throughout the home and included timescales for responses to complaints made and full details of how to contact the Commission for Social Care Inspection. The manager confirmed that two complaints had been received from residents since the last inspection visit in February 2007. Examination of the records demonstrated that both issues had been appropriately dealt with and both residents were satisfied with the outcome. The Commission for Social Care Inspection (CSCI) had not received any complaints since the last inspection visit in February 2007. One resident spoken with was very clear that they would speak to the staff if they had any problems or “would go to Theresa (manager)”. During this inspection visit an advocate from Age Concern visited one resident to make sure she was happy with her stay in the home. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 16 No Protection of Vulnerable Adult (POVA) investigations had taken place since the last inspection visit in February 2007. The manager confirmed that all staff, other than the most recently appointed had attended POVA training with an external trainer and discussion with a number of staff and the manager demonstrated that they were clear about what action would be taken in the event of any allegation of abuse being made. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was generally clean, tidy and comfortable however, some areas of the home could place residents at risk. EVIDENCE: At the time of this inspection visit building work was being carried out in order to turn two double rooms into single rooms with en-suite facilities and to provide a further two single rooms plus en-suite facilities. Discussion with the builders who were on site at this time said that work would be completed in approximately three weeks time. Disruption to residents was minimal and no major building work needed to be carried out. Work had also been started in the laundry area, which is to be converted into a small smoking room and the laundry will be re-sited in the basement. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 18 Many of the bedrooms seen were in need of redecoration and in some cases, in need of furniture being replaced. Discussion with the manager confirmed that this work would be started when building work was finished and the owners Mr & Mrs Gupta confirmed this. A number of bedrooms seen had also been personalised to reflect the character of the person whose rooms they were. The opportunity was taken to speak with one resident sat in his room and he said, “I like my room it is comfortable and suits me”. Commodes seen in a number of bedrooms (identified to the manager) were in a poor state and must be replaced to maintain the health and safety of the residents using them. The main lounge was comfortably furnished although many of the armchairs were in need of replacement as they are showing signs of wear and tear and could place residents health at risk. Again, both the manager and the owners confirmed that once building work in the home had been completed a full refurbishment programme would take place which included replacing the armchairs, carpet and curtains in the main lounge. The damaged bath in the bathroom near room 2 still needed to be replaced and was a requirement made at the last inspection visit. However, it is acknowledged that this will now be done as part of the building work currently being carried out in the home. Carpets in various areas of the home were in need of deep cleaning or replacement and these were identified to the manager. This work needs to be carried out in order to maintain the health, safety and wellbeing of residents and staff. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels in the home were meeting the needs of the residents and relevant training was being provided. EVIDENCE: Since the last inspection visit on 14th February 2007 there have been numerous changes to the staff team in the home and since that time the manager has employed an experienced person in the role of ‘head of seniors’. This person has overall responsibility for managing and supervising senior care staff. The manager said that the creation of this new role will help to further develop the management team and will support staff to carry out their jobs more effectively. Rotas seen indicated that there was sufficient care staff available to ensure that the residents’ health and personal care needs could be met. Discussion with the manager and those rotas seen demonstrated that no ‘overlap’ of time was available to carry out a handover of information between night and day staff. The manager said that most staff arrived early for their duty and were willing to carry out a handover during this time. It is strongly recommended that consideration be given to identifying ‘handover time’ when next reviewing Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 20 the staffing rotas. This will help minimise the risk of information not being appropriately shared between staff teams. 55 of the care staff team had obtained or were working towards a National Vocational Qualification (NVQ) at Level 2 or above. Opportunities for staff to undertake training had greatly improved. Staff spoken to confirmed that they were receiving appropriate training and that they felt supported by the management team in their roles. Comments included “Plenty of training is made available”. A number of staff files were checked and were found to be in order with relevant pre-employment checks in place. Residents were complimentary about the staff team working in the home and comments included, “We are looked after well” and “Staff are good”. Throughout the inspection, staff were observed spending time with the residents either engaged in some activities or just chatting with a cup of tea. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and owners are experienced and had a clear understanding of where further improvements were needed in order to benefit residents. EVIDENCE: The manager had been in post for a number of months and is not yet registered with the Commission for Social Care Inspection. It was confirmed that she was due to have her interview with the Central Registration Team from the Commission in early October and if successful will become the registered manager of Chestnut House. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 22 At the last inspection visit in February 2007 staff supervision was taking place on a regular basis. However, since that time one to one supervision with staff had become infrequent and this was confirmed in discussion with the manager and by those staff spoken with. It is important that staff receive regular supervision in order to support them in developing all aspects of their care practice and to provide them with opportunities to further develop their career via training. Feedback from staff indicated that the manager provided clear leadership and guidance and was approachable and fair to the staff and comments about the management of the home included, “The manager is really good – knows what she is doing” and “(the) owners are very supportive”. Comments from residents about the management of the home included, “She (the manager) is very good – a nice lady” and “We see Mr and his wife (the owners) every week – they always come around and speak with you – ask how you are”. In order to find out what the residents and their relatives/families think about the service being provided by the home the manager sends out satisfaction questionnaires on a six monthly basis. Four of those returned to the home were seen and all contained very positive comments about the service being received. However, it is recommended that such questionnaires be further developed to include seeking the views and opinions of the service offered by the home from other interested parties such as healthcare professionals and GPs etc. The results provided by returned questionnaires could then be analysed to produce an on-going development plan for the home and the results should also be published in the Service User Guide. A satisfactory system was in place to monitor income and expenditure of residents’ finances. This included an on-going record for each individual resident with receipts being retained for any expenditure made. The returned AQAA form showed that all maintenance records were in order and up to date. Random sampling was undertaken of the fire register, public liability certificate, portable electrical appliances and passenger lift/hoists. Most mandatory training was up to date and ongoing except for the most recently recruited staff and the manager was making arrangements for them to receive the required training. Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 (2) Requirement When medication is given ‘as and when required’ a clear audit trail must be available to show how much medication was administered at any one time and how much medication is left at any one time (Previous timescale 28/02/07 not met) Timescale for action 19/10/07 2. OP9 3. OP19 Medicines must be given to residents at the right time in relation to food intake; receiving medicines at the wrong time can affect their health and well being. 13 (4) (a) All refurbishment work and (c) and 23 repairs identified in this report (2) (b) must be carried out. An action plan must be submitted to the Commission for Social Care Inspection that clearly identifies completion dates for all work. 13 (2) 19/10/07 28/12/07 Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 25 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 OP3 Good Practice Recommendations It is strongly recommended that following assessment of a prospective resident, the manager writes to the resident and/or their representative to confirm that the home can/cannot meet their assessed needs. (a) It is strongly recommended that where action is required to be taken following the review of a care plan this should be carried out within the given timescales. Care plans should clearly demonstrate to all staff how identified care should be given. Wherever possible, care plans should be signed by the individual resident and/or their representative. Risk assessments should be included in the residents’ care plan and be readily available to staff to ensure that any risk identified can be minimised and appropriately managed. 2. OP7 (b) (c) (d) 3. 4. OP12 OP27 An activity programme should be developed to include suitable activities for those residents who may be mentally frail. It is recommended that when reviewing staffing rotas consideration be given to ‘building in’ specific time for a handover of information to be given between shifts without relying on the goodwill of staff to come in early or stay late. It is recommended that when carrying out an audit of the service provided by the home the views of other health care professionals such as district nurses and general practitioners are sought. It is recommended that one to one supervision with all staff takes place on a regular, structured basis. 5. OP33 6. OP36 Chestnut House Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Care Home DS0000067980.V349154.R01.S.doc Version 5.2 Page 27 - 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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