Inspection on 27/10/05 for Chestnut View Care Home

This inspection was carried out on 27th October 2005.

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 15/06/06

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 27th October 2005 10:30 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.V259731.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V259731.R01.S.doc Version 5.0 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 Mrs Julie Ann East Care Home 42 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (34) of places Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Additionally, one (1) named service user aged 64 years of age may be admitted in the OP category. Up to eight (8) of the forty-two (42) service users may be accommodated for nursing care. 6th July 2004 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 forty five (45) 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 is undergoing a significant refurbishment including part of the garden. St Cloud Care plc purchased the property from Surrey County Council, the previous owners in November 2001. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection on the 27th October replaces the recent unannounced inspection as agreed with the proprietors of the home and the Commission for Social Care Inspection (CSCI). The inspection on the 27th October was carried out by two inspectors and took eight (8) hours. The home is subject to a protection of vulnerable adults investigation and further information and reports will be reported in a separate forum. The CSCI would like to extend their appreciation of the welcome they received and the assistance provided by the manager and other members of staff throughout the inspection. A number of residents and members of staff were spoken to during the inspection. A tour of the building took place including the external areas and a number of records were sampled for example staff personnel files, resident files including care plans and risk assessments. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements are made to ensure the home provides an effective and consistent procedure to assess the needs of the residents and further ensure that they are able to meet the needs of those residents. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 6 A number of minor works and repairs were required to provide a more personalised and homely feel to the establishment and to complete the development of those areas. Fire evacuation procedures required review due to the individual needs of a number of the residents and their lack of knowledge regarding evacuation in the event of a fire. The evacuation areas required clearing to enable safe passage in the event of fire. The full range of requirements are noted at the end of this report. 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.V259731.R01.S.doc Version 5.0 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 View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 The home provides a pre-admission assessment for prospective residents. EVIDENCE: Standard 6 does not apply; the home does not offer a service for those individuals requiring intermediate care. The home undertook a basic needs assessment of prospective residents. The assessment included information regarding the specified persons previous address and profession, the name of their General Practitioner and their religious faith (if expressed). The pre-admission assessment outlines those areas where care and support would be required. The home provides a small number of placements to those assessed as having nursing needs. The home employs a number of nurse qualified staff and also uses nurse qualified agency staff to cover some of the shifts within the home. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 9 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 The home used a number of comprehensive assessment tools to assess the needs of residents. However further work is required to ensure that the assessment processes in use are appropriate and consistent. The procedures for the recording of medication administration require review to ensure that the information provided is accurate and up to date. EVIDENCE: A number of resident files were sampled. The home used separate nursing and residential care assessment processes to detail the individual needs of the residents. There was concerned that the two distinct processes may provide an inconsistent approach to assessing the level of need required by specified residents. For example a specified person who was refusing essential support required to safeguard their wellbeing was not identified as being in high need; whereas a specified person who required supervision to assist in meeting their required needs was identified as being in high need. A requirement was made that the home review the use of the nursing and residential assessment processes in order to ensure that those with assessed needs other than nursing could also be identified as being in high need dependent on their needs. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 10 Risk assessments were evident on each of the resident files sampled. However evidence of specific risk assessments for specified residents were unable to be located; for example the refusal of essential support in one instance and in another the use of bed rails. The risk assessment format provided strict guidance on areas to be covered. There was no eventuality for additional risks to be identified and assessed. A requirement was made that the home ensure that appropriate risk assessments are undertaken for each resident taking into account their assessed needs. All the care plans sampled contained a hand written note stating that the care plans had been verbally agreed by the specified resident. The note did not identify the reason for verbal agreement only. A requirement was made that care plans and risk assessments are wherever possible signed by the resident or their representative. Where this is not possible the reason must be documented and recorded. The care plans sampled included information regarding the health needs of the residents and how they were being met; for example the contact names and addresses of a specified persons psychogeriatrician (a specialist doctor for older people), District Nurse and optician. Within the resident files sampled there was evidence of the use of assessments identifying nutritional needs and highlighting those residents that may be at risk from developing pressure sores. Most of the residents spoken with stated that they felt their needs were being met although some seemed unaware that other agencies may be available to assist in meeting their more specialist needs such as visual impairment. The outgoing manager undertook moving and handling assessments where required with residents. There was no confirmation of how this need was to be satisfactorily met after the 27th October 2005. A requirement was made that the home inform the CSCI of how they intend to meet the moving and handling assessment needs of the residents. A number of the printed administration of medication records was sampled. Some of the medication administration records had no record of the actual frequency and dosage required, the records note ‘as required’. These were hand written amendments. The home is advised to ask the pharmacy provider to ensure appropriate instructions are printed on the medication administration record. The instructions were noted on the medication packaging. One record had three signatures missing and evidence of a risk assessment with regard to the regular refusal of key medication could not be located. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 11 The CSCI had previously brought to the attention of the home the temperature levels within one of the treatment rooms. The home had documented regular checks on the temperature of the room and these were seen to be consistently higher than recommended within the Pharmaceutical Guidelines. The other treatment room had been fitted with a fan to assist in reducing the temperature of the room. Those residents spoken with considered that staff supported them in a way that was respectful. In general this was noted in practice. There were a few occasions where maintaining residents dignity may have benefited from more proactive staff assistance for example ; a specified resident was noted as requiring assistance in ensuring that clothing was appropriately and sensitively adjusted following a visit to the toilet. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 12 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): 12,14 The home provided a range of regular programmed activities further work is required to ensure that all the residents preferred options are taken into account. EVIDENCE: Standard 14 was not fully assessed during the inspection on the 27th October 2005. However information based on evidence gained through the assessment of other standards would indicate that the home might struggle to maximise the personal autonomy and choice of residents. Please see the Staffing section of this report. Some positive comments were made about the activities programme, it was clear there was a regular programme of activities that took place. Some negative comments were also received and it was less clear how people who did not want to participate in the regular activities would have their needs met. A requirement was made that the home review the activities programme with, wherever possible, the residents. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: These standards were not assessed during the inspection of the 27th October 2005. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 14 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): 19,20,22,26 The home has been subject to considerable refurbishment and building works it was noticeable that a number of minor building works and repairs were outstanding. Further work is required to ensure the home meets The National Minimum Standards Older People and ensures that health and safety is implemented to a satisfactory standard. EVIDENCE: The home had a pervading malodour throughout the resident accommodation. The manager reported that the homes carpet cleaner was broken and that staff members had to spot clean areas of the floor. The manager was unable to state when the carpet cleaner would be repaired or replaced. Those resident rooms seen were clean and hygienic and had been personalised. Some residents said they liked their bedroom. The home was being comprehensively refurbished by the organisation. There was concern at the number of minor works required in a number of areas where dates for completion could not be given. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 15 For example one room, vacant at the time of the inspection had holes across the top of the doorframe and one door of the wardrobe was warped and difficult to close. An area of the home had been subject to flooding and the home was awaiting final agreement from the insurance company before finishing the work required, making good the areas affected. The manager was unable to confirm a completion date for the work. It was brought to the attention of the manager that a large screw that was holding the call button plate of the lift away from the wall. The manager dealt immediately with the matter arranging for the screw to be removed and enabling a safer option to be provided. One of the bathrooms seen had been refurbished and a new assisted bath had been installed. The tiling in the bathroom had not yet been replaced; the manager was unable to offer a date for completion of the work. In the same bathroom a hoist was present that required repair to the base. In a number of areas carpet joins were being held together with wide tape, the manager reported that the home were waiting for the carpet fitter to return to the home to complete the work. A date for completion was not available. One of the home’s two washing machines had broken down on the 19th October 2005. A member of staff advised that the machine had broken down several times and that they now have agreement to purchase a new machine. A delivery date was not available. The home was said by the manager to be able to cope with one washing machine in the interim. A requirement was made that the home provide the CSCI with an action plan showing when these and any other outstanding minor works would be completed. Both the dining areas were seen during the inspection of the 27th October 2005. The Inspectors found that the cutlery had been stored unclean and in an unclean drawer. The storage containers for dried cereals were also unclean. A requirement was made for the areas to be cleaned and kept clean. The home has a daily quality assurance check however those documents seen did not include the cleanliness of areas within the home. A requirement was made that the home provides a regular detailed check of all areas of the home in order to ensure improved standards of cleanliness. The Inspectors found two further storage containers, of the same kind, in the kitchen. These were seen to have unclean lids. The remaining storage containers in the kitchen were clean. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 16 Disposable gloves and bin bags were available for use in the bathrooms. The manager stated that further developments in the home would increase storage therefore there were no requirements or recommendations made. External works were in hand to complete the landscaping of the garden. To the rear of the building raised flowerbeds had been built and contained strong smelling herbs that could be reached by wheelchair users as well as those with good mobility. Additional lighting was being installed to further improve the area. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 17 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 Further work is required to ensure that the recruitment and deployment of staff meets the assessed needs of the residents. EVIDENCE: The CSCI were informed that prior to the 25th October 2005 the home employed four staff members for the morning and afternoon shifts. Since the 25th October the staff numbers had increased to five for the morning and afternoon shifts. Key workers are allocated to each of the residents and staff members were expected to key work individuals over two floors of the home. Residents spoke highly of most staff and considered where they were not happy they could talk to the management about this. The home had a staff rota showing which members of staff were expected to attend for work each day. On arrival at the home the manager or deputy manager then deploys the staff members in specific areas. On the day of the inspection the information provided by both documents was misleading. The main rota had not been adjusted to reflect the changes required on the day. The document recording where staff members were deployed during their shift was only able to evidence three staff working from 7.30am covering 31 residents. The deputy manager advised that the rota was incorrect and that the remaining two staff had begun work at 7.30am. A requirement was made Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 18 that the home ensure that the staff rotas are correct and accurately reflect the staff numbers on duty and where they are deployed. For example on the day of the inspection two staff members were providing support for residents to undertake activities, the session was taking place on the top floor, leaving three staff to cover three floors and those residents who did not wish to take part in the activities session. The CSCI were unable to confirm that the staffing numbers and skill mix met the needs of the residents. The inconsistency of assessment created by the use of separate residential and nursing needs assessment forms, the lack of specific risk assessments relating to safeguarding the needs of specified residents and the manner in which staff are deployed led to a lack of evidence that the home were able to meet the needs of residents. A requirement was made that the home review staffing levels taking into account the outcomes from the required review of the nursing and residential needs assessments and the outcomes from the required additional specific risk assessments. The home recorded the training that had been completed by the staff members. The information included the training course and whether they had completed or were completing the National Vocational Qualifications (NVQ) Level 2. The home did not have a detailed training or development plan that included when refresher training was due nor was there evidence of specialist training taking place that recognised the needs of the residents, for example, mental health and visual impairment. The outgoing manager had provided moving and handling training and the CSCI were informed that the manager may return to the home to undertake some work in the role of nurse qualified staff. However it was uncertain how the home was going to ensure that staff received adequate training in the future. As noted previously the outgoing manager also undertook moving and handling assessments where required for residents. A requirement is made that the home informs the CSCI how they intend to meet the training needs of staff in respect of moving and handling. The Inspectors took time to inspect the home on the 27th October 2005 and it was not possible to fully inspect Standard 28 of The National Minimum Standards for Older People. The staff members spoken with during the inspection were able to discuss the home’s training provision and inform the inspectors of those training courses they had attended. A number of staff files were sampled and it was not possible to locate all the information required to ensure the home had followed the necessary Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 19 recruitment process. For example; of the two references found in one file neither noted the relationship with the prospective employee, only one reference was found in another file and in another no evidence was found of a check being carried out regarding a work permit. The induction process in some instances had not been signed and dated and in another example no record of the person’s training was found. A requirement was made to ensure that the recruitment procedure is reviewed and that all the documents required by The Care Homes Regulations 2001 (as amended) are available within the staff files. The Criminal Record Bureau (CRB) checks were held on the staff file. A requirement was made that the home review the Criminal Record Bureau Guidance to ensure appropriate storage, recording of key data and the timescale of disposal of the original document were within the guidance provided. The staff personnel files sampled held copies of documented supervision sessions. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 20 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): 31,33,36, 37,38 The home is going through a period of staffing changes and further work is required to ensure that any interim management arrangements safeguard the assessed needs of the residents. A number of minor works and repairs required work to ensure the premises met The National Minimum Standards Older People. EVIDENCE: The members of staff spoken with on the day of the inspection were able to say how decisions were made by the home on behalf of residents. A clear process was in place to enable care staff to inform senior staff and/or management of changes in a resident’s needs the senior staff and or manager would then undertake their own checks before making any decision as to how those changes might be reflected in the care plan. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 21 The 27th October 2005 was the last day at work for the nurse qualified registered manager. The organisation had informed the CSCI of the management arrangements they would put in place until the new manager was able to take up their post. The registered manager was unable to specify a start date for the new manager. In the interim the CSCI were informed that the deputy manager will oversee the residential provision, the nurse qualified member of staff will oversee the nursing provision and a senior staff member of another home will attend the home on two days each week. The CSCI were concerned at the arrangements given the issues identified through the inspection on the 27th October 2005. The manager informed the inspector that regular fire alarm tests and fire drills took place. The records seen sampled confirmed the information given by the manager. In discussing fire evacuation procedures with a specified resident it was found that they were unaware of the procedures and had assumed that they would have to make their own way out the building and stated that they had not personally seen any fire exits this did not meet the specific needs of the resident. The manager reported that the home had been inspected by the Fire safety Officer; no written report was available. As previously noted in the Environment section of this report debris and builders material had been found in the fire evacuation area and this with the residents lack of knowledge of the fire evacuation procedure was of concern. The deputy manager stated that the home has a stay put policy for safeguarding residents in the event of a fire. A requirement was made that the home request a further inspection by the Fire Safety Officer taking into account the matters raised and to include a discussion regarding the stay put policy. The areas where work was being undertaken were also used for fire evacuation. A number of items had been left on the paths including large heavy drain covers. One of the paths had been completely blocked by builders’ materials and debris, a ladder and flex had been left by an entry into the home. These matters were brought to the attention of the manager at the time. A requirement was made that the home ensure that all fire evacuation areas are kept clear from all debris at all times. The kitchen and laundry areas were inspected on the 27th October 2005. As noted previously in the Environment section of this report two storage containers in the kitchen had dirty lids. A requirement was made to clean the containers or replace with an alternative container. The kitchen was found to be clean; the kitchen staff were in the process of clearing up after the lunch period. The cook said that the temperature of hot food was taken in the kitchen but not at the point of delivery. A recommendation was made that the home discusses this with the Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 22 Environmental Health office in order to ensure that this practice meets any food safety requirements. The laundry area was clean and tidy. It has been noted elsewhere in this report that one of the washing machines required replacing. None of the strip lighting in the laundry area was covered and a requirement was made to ensure that the lights were provided with protective coverings. A number of the rooms seen during the inspection had cracks in the walls; the settling process following building work may cause these. As noted previously the home is in the process of a major refurbishment programme and there were a number of areas where work remains outstanding. A requirement was made in the Environment section of this report regard those outstanding works. The home ensured provision of up to date information regarding the safe use of chemicals hazardous to health (COSHH). The information was kept in the cupboard alongside the chemicals in use and other cleaning materials. Members of staff reported that regular training in COSHH took place and refresher training was provided should staff be away from work for a period of time. Discussions with staff indicated this area of practice was understood well and practiced effectively. In one of the bathrooms a laundry basket for the storing of dirty laundry was found without a lid, the manager acted on this matter immediately ensuring a lid was provided. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 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 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 2 X 3 X X X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 3 2 2 Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 24 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 7 Regulation 15(1)(2) (a-d) Requirement The registered person must review the use of separate nursing and residential assessments in order to ensure a consistent approach to meeting the needs of the service users. The registered person must review the risk assessment document to ensure that all aspects of daily living are risk assessed where required including the use of bed rails. The registered person must ensure that wherever possible the service user, their relatives or representative sign the care plan and risk assessments. The registered person must inform the CSCI of how they intend to ensure service users lifting and moving needs are assessed appropriately. The registered person must review the home’s policies and procedures with regard to the recording, handling, safekeeping, safe administration and disposal of medication. Timescale for action 30/12/05 2 7 13(4)(a) (b)(c) 30/12/05 3 7,37 15(1)(2) (a-d) 30/12/05 4 8 13(4)(c) 05/12/05 5 9 13(2) 05/12/05 Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 25 6 9 7 12 8 19 9 26 10 27, 37 11 27 12 29, 37 13 29,37 14 30 The registered person must ensure that the temperature of the medication storage area does not rise above 25 degrees to ensure safekeeping of medications. 17(2),15 The registered person must review the programme of activities with, wherever possible, the residents to ensure that the needs and wishes of all can be documented and taken into account. 23(2)(bThe registered person must c)(16)(2)( provide the CSCI with an action k) plan regarding the completion dates for all the minor works, repairs and replacements required and noted within this report. 23(2)(d) The registered person must implement a cleaning rota to ensure that all areas of the home are cleaned and kept clean. The registered person must 17(2) Sch’ ensure that the staff rota and 4(7) documents recording staff deployment are accurate. 18(1)(a) The registered person must (b) review the staffing levels of the home taking into account the reviewed nursing and residential assessments and the wider risk assessments provided. 19(1)(a) The registered person must (c)(4)(aensure that the recruitment and b) selection process meets the requirements of The Care Homes Regulations 2001 (as amended) 17(2),Sch The registered person must 4(6)(f),19 review the storage, recording and disposal of CRB checks in line with guidance provided by the Criminal Record Bureau and The Care Homes Regulations 2001 (as amended). 18(1)(a) The registered person must ensure that a training DS0000013849.V259731.R01.S.doc 13(2) 30/12/05 30/12/05 30/11/05 30/11/05 30/11/05 30/12/05 30/11/05 30/11/05 30/12/05 Page 26 Chestnut View Care Home Version 5.0 15 30 18(1)(a) 16 31 8(1)(2),9 (1)(2) 17 31 8(1)(2),9 (1)(2) 18 19 38 38 23(4)(b) (c)(iii) 23(4)(c) (iii)(e) development plan is implemented and takes into account the specialist needs of the service users for example mental health. The registered person must inform the CSCI in writing of how it intends to ensure the provision of moving and handling training to staff. The registered person must inform the CSCI in writing how it intends to ensure the induction of the new manager taking into account their support needs. The registered person must inform the CSCI in writing of their plan to ensure appropriate management of the home until such time as the new manager starts work. The registered person must ensure that the fire evacuation areas are cleared and kept clear. The registered person must liaise with the Fire Safety Officer with regard to the fire evacuation process including the homes stay put policy and informing the residents of the fire evacuation procedure. 30/11/05 30/11/05 27/11/05 27/11/05 30/11/05 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 38 Good Practice Recommendations It is recommended that the home liaise with the Environmental Health Office regarding the taking of food temperatures in the kitchen only and not at the point of delivery. Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Chestnut View Care Home DS0000013849.V259731.R01.S.doc Version 5.0 Page 28 - 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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