Inspection on 15/06/06 for Chestnut View Care Home

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chestnut View Care Home 02/04/09

Chestnut View Care Home 16/07/07

Chestnut View Care Home 13/03/07

Chestnut View Care Home 27/10/05

Chestnut View Care Home 30/08/05

Chestnut View Care Home 06/07/04

Chestnut View Care Home 19/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Chestnut View Care Home Chestnut View Care Home Lion Green Haslemere Surrey GU27 1LD Lead Inspector Susan McBriarty Unannounced Inspection 15th June 2006 09:00 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 View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chestnut View Care Home Address Chestnut View Care Home Lion Green Haslemere Surrey GU27 1LD 01428 652622 01428 651145 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) St Cloud Care Plc Susannah Stanesby Care Home 60 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (48) of places Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Up to twenty (20) of the sixty (60) service users may be accommodated for nursing care, four (4) of whom may be terminally ill (TI). 27th October 2005 Date of last inspection Brief Description of the Service: Chestnut View is a large detached property set in private gardens. The service currently provides twenty-four (24) hour care for up to sixty (60) older people. The property is close to the local town centre and is within walking distance for those who are able to walk short distances. The home has undergone significant refurbishment including the garden; a separate unit for service users with dementia has been opened. The dementia unit has a separate garden for their use. St Cloud Care plc purchased the property from Surrey County Council, the previous owners in November 2001. Fee levels for 2006-2007 are as follows: levels shown are minimum to maximum fees charged. Residential £540 to £565 Residential respite care £575 Residential with nursing £680 to £715 Residential with nursing respite care £690 Dementia unit £675 Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the inspection year 2006 –2007 under Inspecting for Better Lives. The inspection was a ‘key’ inspection and considered all the key standards, which are noted within the report. In addition the inspection report contains a judgement noting whether the home is poor, adequate, good or excellent at meeting the outcome areas. The outcome for this inspection is adequate. The inspection began at 9.15 am on the 6th June 2006 and was carried out by one inspector over two dates, the second date being the 15th June 2006. During the inspection a tour of the home took place and a number of documents were sampled including; pre-admission assessments, care plans, medication administration records, health and safety records and service user finance records. A number of service users and staff were spoken with and nine (9) comment cards were returned to the CSCI prior to the report being in draft. Additional evidence was provided by the pre-inspection report received by the CSCI on the 29th June 2006 and the Regulation 37 notifications received by the CSCI since the inspection of 27th October 2005. In total fifty two (52) Regulation 37 notices have been received by the CSCI. The notifications indicate improvement within the home as fewer are being made containing information about injuries due to falls. The inspection report notes substantial improvement in the running of the home, records and documentation had also improved. What the service does well: What has improved since the last inspection? There is a clear management structure within the home and members of staff including the deputy manager were clear about their roles and responsibilities and the expectations of them as part of the staff team. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 6 The recording of information was improved and the documents provided for recording had also been improved reducing the risk of confusion regarding the assessed need of a service user. New files had been provided that enabled easy access to the information. The inspection found the members of staff to be more open to the inspection process and they raised no concerns during the inspection. The building work had been completed and the grounds cleared and grassed areas and plants had been provided, a separate area for those with dementia had also been completed and made available for use. The entrance to the home is now open and more welcoming having been provided with furniture and music is often played quietly. The home now has an activities co-ordinator in post and they are working with the manager to ensure the needs of the service users are assessed, documented and accurate records kept. What they could do better: Whilst improvement was evidenced during the inspection a number of areas require further work to ensure that the policies and procedures, documents and records made for and kept by the home regarding service users and members of staff are consistent, up to date and reviewed regularly for example: The statement of purpose and service user guide require revision and updating to ensure that service users and/or their representatives know what to expect from the home should the prospective service user decide to move in. Care plans and risk assessments had been revised however they had not consistently been kept up to date and the involvement of service users and/or their representatives was not evident. Employment records had received attention however further work was needed to ensure that all the files contained the information required by The Care Homes Regulations 2001 had been provided. The cultural and religious needs of the service users were unclear and the information needs to be gathered by the home to ensure that the service users needs are being met. Policies and procedures to safeguard service users from abuse require revision to ensure they support Surrey County Council’s multi-agency procedures for the protection of vulnerable adults. The requirements and recommendations made during this inspection are available at the end of this report. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 7 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 View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 8 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 View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was required to ensure that service users or their representatives were able to make a decision about moving to the home and all the information required to meet the assessed needs of service users was recorded. EVIDENCE: The statement of purpose did not contain the information required to assist service users and/or their representatives to make a decision about moving into the home. However the service user guide contained some of the information that was missing. The information required included members of staff qualifications and experience and clear information regarding access to the Surrey County Council local Social Services team. A requirement was made that the statement of purpose and service user guide are reviewed and updated appropriately. A number of service user’s files were sampled. Copies of the organisation’s and social services contracts had been provided appropriately and were held on the files. The organisation’s contracts informed service users that The National Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 10 Care Standards Commission (NCSC) could be contacted if there were any difficulties. A requirement was made that the organisation confirms that the contracts had been revised to change the information provided to the Commission for Social Care Inspection (CSCI). Significant improvement was found. The new manager had revised the preadmission assessment forms to ensure that all service users entering the home had been assessed appropriately and in a consistent manner. The home now has one assessment process to follow enabling more accurate recording of service users needs. The pre-admission assessments seen did not all clearly record the date of admission. A requirement was made for the date of admission and any other details required by Schedule 3 of The Care Homes Regulations 2001. The pre-admission assessment information was in the process of being further revised by the organisation to ensure a consistent approach was taken across the homes owned by them. The new assessment forms will be used for new service users entering the home. The revised pre-admission assessments enabled the home to ensure that the assessed needs of the prospective service user could be met. The manager informed the CSCI that service users and /or their representatives are not required to make an appointment to visit the home. Members of staff had been informed visitors may arrive at any time and that they are to be made welcome. Standard 6 does not apply, as the home does not provide intermediate care. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall service user health and personal care needs are met, however some areas require further improvement. EVIDENCE: Improvement was found with regard to care planning and risk assessment. The care plans and risk assessments were held in an accessible folder and documents were easily accessible and understandable. One care plan format was in use reducing the risk of lack of clarity regarding the needs of any service user. Care plans had been revised and information updated on all service users living at the home before January 2006. The information compiled included social and health and safety needs. However the care plans sampled had not received a documented review each month and there was no recorded evidence of the involvement of service users. A number of the files sampled recorded review of risk assessments on a regular basis, members of staff had not completed all the documentation required by the organisation to confirm those reviews had been completed. One service user required bed rails and a risk assessment could not be located in the individuals file. A requirement was made that the home confirm that a risk assessment regarding Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 12 the use of the bed rails had been completed and available on the service user’s file. A requirement was also made that the home ensures that the care plans and risk assessments are reviewed each month and the reviews documented according to the home’s procedures. Where appropriate the service users or their representatives must be involved and sign agreement to the care plan and/or risk assessment. Care plans that had been further revised were being introduced into the home; these were to be put in place for service users new to the home. The revised care plans documented the information required in Schedule 3 of The Care Homes Regulations 2001. Records written by members of staff were generally in good order and included what action had been taken following incidents and or accidents. On occasion such records had not been made and a requirement is made to ensure that all records identify what action members of staff took and the outcome. The health care needs of service users were recorded and any action required documented. This included fluid charts, waterlow assessments and manual handling assessments. The top floor of the home has been set aside for the provision of nursing care to those whose assessed needs require nursing. The manager confirmed that nurse qualified staff carry out the nursing tasks required to ensure the assessed needs of service users are met. It was also confirmed by the manager and deputy manager that in the residential and dementia care unit the assessed health needs of the service users are met by the local District Nursing services. The District Nurses attend the home at least twice a week and the manager confirmed that the district nurses record any action taken by them to meet the service users health needs. Members of staff at the home make a separate record to confirm the action taken. The local General Practitioner (G.P) was spoken with during the inspection. The G.P stated that there had been improvement in the home and noted that the deputy manager was ‘meticulous’ regarding the administration of medication and would check with the G.P if there were any queries raised regarding a service users medication requirements. The G.P confirmed that they attend the home at least weekly and would attend any service user that was considered by the home to require review and at any service user’s request. The administration of medication was sampled across each area of the home. Some issues were raised through the sampling. One service user in receipt of respite care had been admitted with a set of instructions by a relative that did not match the prescription, one tablet had been popped from the blister pack and returned but signed as administered and a laxative medication had not been administered and no record made of the reason. The deputy manager was aware of one of the matters raised and was due to discuss the matter with Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 13 the G.P the remaining issues required further work by the home to investigate what had happened. A requirement was made that the home reviews the home’s policies and procedures for the administration of medication and ensure that members of staff are following those policies and procedures. The treatment room temperature was still high although an air conditioning unit was in place and working, records of the temperature noted a relatively consistent temperature of 28c. The recommended temperature for the storage of medication is 25c or below. An email was seen stating that another air conditioning unit was to be supplied. A requirement was made that this matter be confirmed. Those service users spoken with during the inspection confirmed that members of staff respect their privacy and treat them with respect. The comment cards received by the CSCI further confirmed that service users are treated well by the home. Where service users were unable to voice their views due to dementia or other issues members of staff were observed offering a quiet and calm approach to meeting service user needs. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Good progress had been made in meeting the social and leisure activities of the service users. Further work was required to ensure that the home was fully aware of the religious and cultural needs of the service users and whether those needs were being met. The home also needs to seek ways to ensure that service user views and wishes are documented, recorded and outcomes clear. The home provides fresh cooked meals each day and provide a varied menu. EVIDENCE: The home had employed an activities co-ordinator and the sessions attended and who by was documented and recorded. The manager stated that they wished to see further improvement regarding recording. Records were sampled that evidenced a variety of leisure and social activities including attending church, playing bingo and holding discussions with service users. Information about the cultural and religious diversity of service users was not held centrally and it could not be confirmed by the manager that these needs were being met. A requirement was made that the home confirms the cultural and religious needs of service users to ensure their needs could be met. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 15 Family and friends were able to visit the home at a time of their choosing; this was confirmed in discussion with some service users during the inspection. A number of the service user spoken with talked about when they saw their relatives and what they did together. Observations during the inspection and discussion with some of the service users confirmed that choice and autonomy was respected by the home. However further work is required to ensure that decisions and feedback from service users was recorded including what action was taken with regard to the choices made or the feedback received. The organisation was in the process of drafting a quality assurance process and it was required that service users and their representatives are fully included throughout the process to ensure their views are sought regarding all the services provided by the home (see also management and administration). Meals in the home were all made from fresh ingredients and the menu was seen as varied. The inspection took place over two days and two main meals were seen, these were served hot and looked appetising. The service users spoken with made very positive comments regarding the food served. The comment cards received by the CSCI confirmed that the meals were enjoyed; one service user commented that the meals were too big. Service user views regarding the meals were sought verbally and the manager and chef stated that ideas were acted upon as were any changes suggested, where possible. It was recommended that service user views were recorded in order that that the action taken could be confirmed both as part of a quality assurance audit and during the inspection process. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Further work was required to ensure that service users are safeguarded by the home’s policy and procedures regarding complaints and the protection of vulnerable adults. EVIDENCE: The home has a complaints procedure in place however minor variation was required to ensure that service users and/or their representatives were clear about who was who in the policy. For example that the ‘local office’ was social services. A requirement is made that the complaints policy and procedure is reviewed and revised to ensure service users and/or their representatives are clear about what to do if they wish to make a complaint. Three (3) complaints had been received by the home since the last inspection, two were investigated by the CSCI and the remaining complaint was investigated by the home. A number of the elements of the complaints investigated by the CSCI were upheld. These matters related to the laundry service and the recording of information. Feedback from one complainant provided confirmation that the home had acted upon the outcome and improvement made. The procedure for the protection of adults requires review to ensure that it supports the Surrey County Council multi-agency procedures for the protection of vulnerable adults. The procedure must ensure that a referral is made to the local social services team for consideration under the multi-agency procedures and not investigated by any person prior to the referral being made. A requirement was made that the policy and procedure be reviewed and revised Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 17 to ensure that members of staff know what action to take in the event of an allegation being made. Discussions with some members of staff during the inspection and training information confirmed that training regarding the protection of vulnerable adults had been provided. No referrals requiring consideration under multi-agency procedures had been received since the last inspection. The manager was unable to locate a whistle blowing policy during the inspection. A requirement was made that a whistle blowing policy is either developed or the organisation confirm that such a policy is in place in order to ensure that members of staff are safeguarded if they wish to inform the organisation of any concerns at work. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building work to the internal and external parts of the building has been completed and improvement observed. A significant number of bedrooms had en-suite facilities and all those seen were clean and had been personalised. Some work was required regarding cleaning and repair in order that the works completed are kept clean and maintained. EVIDENCE: A tour of the building took place and all the communal areas and a number of bedrooms were seen, improvements were observed. Building work had been completed and the dementia unit was open, all the garden areas had been completed and planting had taken place. The home was generally clean and there were no malodours present in any part of the home. Those bedrooms seen had been personalised and service users were satisfied with the fittings provided. A number of rooms were en-suite further enhancing privacy and dignity. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 19 The unit for people with dementia was small in scale with an accessible garden area allowing for additional movement around the unit in good weather. Some work was required to ensure that all areas of the home were clean and kept clean and that matters regarding possible cross infection were consistently dealt with. 1) One of the staircases had stains on the steps and cobwebs under the stairs evidencing that this stairway was not cleaned thoroughly and regularly. 2) Towels were found in some of the bathrooms, this might lead to more than one person using the towel and increasing the risk of cross infection. 3) Some of the air vents in the home require thorough cleaning. 4) The cleanliness of the cupboards in the dementia unit required attention. 5) The door to the garden in the dementia unit could not be opened, as there was a problem with the lock, the matter was dealt with on the day of the inspection. 6) Entry could be made to the garden that was for the sole use of those service users in the dementia unit through another gate. That gate must be kept locked to ensure the safety of service users. This matter was dealt with on the day of inspection. 7) Some areas of the home require attention to the décor as some walls and doors are marked or damaged through wear and tear. 8) The carpet in one area required attention as it was coming up. 9) The areas that had been uncovered or new pipe work had been installed following a leak required making good. 10)Toasters need a thorough clean or replacement. A requirement was made that a detailed review of the home take place to ensure that work requiring attention is detailed and a programme of redecoration is provided to the CSCI. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriately qualified and trained members of staff were on duty. The home’s recruitment policies and procedures were available and were being followed by the home when recruiting new staff. EVIDENCE: Sixty nine (69) members of staff are employed by the home in a range of roles. The roles include nurse qualified staff; care staff, an activities coordinator, domestics and kitchen staff. Twenty eight (28) of the sixty nine (69) are care staff and twenty (20) have a National Vocational Qualification to at least level 2. Thirteen staff are nurse qualified; twelve general trained and one trained in mental health. Nine (9) staff are on duty throughout the home each day and five waking night staff are on duty each night. The manager confirmed that staffing levels would be revised as the number of service users resident in the home increases. The manager was aware that further work was required to ensure that members of staff personnel files contained the information required and work was in hand to ensure those matters were completed. Some staff files were sampled during the inspection and confirmed the information provided by the manager. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 21 Each member of staff had two files one for employment related matters and the second for training information. The manager informed the CSCI the application forms had been updated and now included the requirement to provide full employment information including a reason for any gaps in employment. The files sampled during the inspection evidenced the previous application forms in use. The CSCI observed some of the work in hand to ensure that staff personnel files contained the information required by The Care Homes Regulations 2001. Photographs were in the process of being affixed to information sheets for inclusion in the files. An information matrix had been completed to ensure that the administration of the right to work in the U.K of some staff was available and action could be taken if the necessary information could not be provided to the home. The manager and administrator of the home informed the CSCI that a link had now been made with the Home Office and that any queries relating to the right to work and associated Visa’s can be dealt with quickly and easily. Information regarding the training staff had received had been placed on a central document and was seen by the CSCI. The manager stated that only those training courses that could be evidenced by staff had been included. Where no evidence was available of training the manager had informed staff they would have to attend the training again. Criminal Record Bureau (CRB) checks had been completed on all members of staff and satisfactory PoVA first checks are completed before members of staff are allowed to begin work at the home. Photocopies of the application forms for CRB checks were in place in some files and in one file a copy of a previous CRB check from a previous employer was held. A number of staff had worked at the home for some time and the documents required to confirm their identity had been provided. Further work was required to ensure that all the information required by The Care Homes Regulations 2001 was in place and that the full CRB guidance was being followed. Requirements were made to ensure the work in hand was completed in full. It was recommended that the home consider asking for alternative identity documents in order to remove those that are no longer required as part of the identity check, such as birth certificates. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement in the running of the home, provision of documents and records was found. The manager is nurse qualified and arrangements made for further management training. The financial and business plan of the home was not inspected during the inspection. Supervision has begun at the home and the registered persons need to ensure that six supervision sessions are provided each year to each member of staff. Health and safety checks had been completed and the home had compiled readily accessible documents to evidence those checks. EVIDENCE: The registered manager is nurse qualified and will begin the registered managers award shortly. This is their first post working in a care home although they had managed other services. The service users and members of Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 23 staff spoken with during the inspection felt that the manager had made improvement to all aspects of the running of the home. The manager was supernumerary to the staff team and this has assisted with the amount of work required to assist the home to run the way it should in order to ensure service users assessed needs are being met. This must continue at least until such time as all the work required has been completed and the home is consistently meeting the National Minimum Standards for Older People and The Care Homes Regulations 2001. The organisation had a draft quality assurance process in consultation at the time of the inspection. The document must include more information about how the home intend to gain the views of the service users and/or their representatives as part of each category of the audit. The organisation intends that part of the audit would be completed each month. It was not clear how the results of the audit would be published and made accessible to service users and the wider public. The financial and business plan for the home was not requested during the inspection and a requirement is made that a copy be forwarded to the CSCI for information. The home does assist a number of service users with their finances. The records were sampled and all those checked were found to be correct. The procedure and documents for recording had been revised and were found to be clear it was recommended that at the top of each new page a note is made that the money had been brought forward as no note had been made to identify where the sum of money had come from. All other entries were clear. Supervision for staff began in March 2006 with the majority taking place in May 2006. A record had been kept of the dates of each supervision session. The management of the home need to be mindful that six sessions per year for each member of staff supervision should include all aspects of practice, philosophy of care within the home and career development needs. Improvement was found regarding the keeping of documents and records and although the care plans and risk assessments required further work to ensure they remain up to date the records were clear and accessible. The care plans and risk assessments were readily accessible to members of staff ensuring that they were in use on a constant basis. This was evidenced as the CSCI were sampling the records and members of staff were requesting access to ensure they could record what they had done as soon as possible after completion of a task. Policies and procedures to safeguard the service users living in the home required revision and updating to make clear that they support the Surrey County Council multi-agency procedures for the protection of vulnerable adults. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 24 All health and safety checks sampled were up to date and evidence of completion available apart from gas safety. The gas certificate was held at head office, a requirement was made that all certificates confirming safety checks must be available for inspection. An email was seen confirming that a gas safety check was being carried out on the 16th May 2006. Fire safety records were sampled: Fire attendance record completed 12/06/06 Fire alarm system checked 7/6/06 Alarm bell checked 9/11/05 Fire risk assessment completed 26/5/06 Last fire drill 6/6/06 with records to show what action was taken and time taken. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 25 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 2 2 2 3 3 X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 3 Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 26 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 OP1 Regulation 4,5 Requirement The registered persons must review and update the statement of purpose and service user guide to ensure they contain all the information required. The registered persons must ensure the organisation’s contract of terms and conditions is updated to include the CSCI. The registered persons must review the pre-admission information held to ensure that all the information required in Schedule 3 is available. The registered persons must ensure that care plans and risk assessments are reviewed at least monthly and where appropriate signed and agreed by the service user and the outcomes documented. The registered persons must confirm that a risk assessment has been completed regarding the specified service user and that a copy is on file and open to inspection. The registered persons must ensure that all records made by DS0000013849.V293062.R01.S.doc Timescale for action 21/08/06 2 OP2 5 21/08/06 3 OP3 14 28/07/06 4 OP7 12(3),15 28/07/06 5 OP7 13(4)(c) 30/06/06 6 OP7OP8 13(4)(c) 17(1-4) 30/06/06 Chestnut View Care Home Version 5.1 Page 27 7 OP9 13(2) 8 OP9 13(2) 9 OP12OP15 12(4) 10 OP16 22 11 OP18 13(6) 12 OP18 13(6) 13 OP19 23(2)(b) (d) members of staff evidence what occurred, what action was taken by staff and the outcome. The registered persons must review the home’s policy and procedure regarding the administration of medication and ensure that members of staff are following the procedure. The registered persons must confirm that further or improved air conditioning has been provided for the treatment room to ensure the temperature remains at 25c or below. The registered persons must ensure that the cultural and religious needs of the service users is known, recorded and action taken where required to ensure the service users cultural and religious needs are met. The registered persons must ensure the complaint procedure makes clear the names and addresses of those who can be contacted by service users and/or their representatives. The registered persons must ensure that the home’s policy for the protection of vulnerable adults supports Surrey County Council’s multi-agency procedures for the protection of vulnerable adults. The registered persons must confirm that a whistle blowing policy is in place or ensure a policy and procedure is produced for the home. The registered persons must carry out a detailed review of all areas of the home and ensure that any repairs or re-decoration needs are carried out and made good including those areas noted in this inspection report and that a programme of re-decoration DS0000013849.V293062.R01.S.doc 30/06/06 30/06/06 28/07/06 30/06/06 21/08/06 21/08/06 21/08/06 Chestnut View Care Home Version 5.1 Page 28 14 OP29 19 15 OP29 18,19 16 OP33 24 17 OP34 25 18 OP36 18 made available to the CSCI. The registered persons must ensure that members of staff employment files contain the information required in Schedule 2 of The Care Homes Regulations 2001. The registered persons must review the procedure regarding the safekeeping and disposal of Criminal Record Bureau checks to ensure the home meets the guidelines set out by the Criminal Record Bureau. The registered persons must ensure that service user’s views are sought across all areas of the organisation’s quality assurance process and confirm how they intend to ensure that service users and/or their representatives will be informed of the outcome and action required. The registered persons must forward a copy of the home’s business and financial plan to the CSCI. The registered persons must ensure that members of staff receive at least six supervision sessions per year. 28/07/06 28/07/06 28/07/06 28/07/06 28/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard AP15 AP29 Good Practice Recommendations It was recommended that the views of service users regarding meals and mealtimes are documented and recorded in order to confirm the action taken. It was recommended that the registered persons consider DS0000013849.V293062.R01.S.doc Version 5.1 Page 29 Chestnut View Care Home 3 OP34 updating those staff files that contain the information previously required to confirm the identity of members of staff to the information now required by The Care Homes Regulations 2001. It was recommended that the term brought forward or other similar term be used to identify where monies noted on a new record sheet were from. Chestnut View Care Home DS0000013849.V293062.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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