Inspection on 09/05/05 for The Chestnuts

This inspection was carried out on 9th May 2005.

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 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

The Chestnuts 07/11/06

The Chestnuts 08/06/06

The Chestnuts 12/12/05

The Chestnuts 07/09/04

The Chestnuts 01/04/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 The Chestnuts 14 St Helens Road London SW16 4LB Lead Inspector James OHara Announced 9 May 2005 09:30 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Chestnuts Address 14 St Helens Road London SW16 4LB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8765 0299 Mr Michael McDonagh Mrs Denise McDonagh Care Home 5 Category(ies) of Learning disability (5) registration, with number of places The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 07/09/04 Brief Description of the Service: Chestnuts is Registered as a home offering support to five adults with learning disabilities and either Autism or Aspergers Syndrome. Chestnuts is a large detached house located in the heart of Norbury and is only a few minutes walk from local shops, rail and bus services. Chestnuts has five single service user rooms, with a bathroom being located on the first floor of the home and a shower room situated on the second floor of the home. The lounge is large and comfortable. The wood-panelled dining room is a good size, providing a valuable additional communal space for service users. The home also has a large well maintained back garden with garden furniture and barbeque, which the service users make good use of. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection took place over one day. Methods of inspection included a tour of the premises observation of contact between staff and service users, discussion with service users, the home manager and the registered provider, communication with the new service users advocacy group and a telephone conversation with one of the service users relatives. A large number of comment cards were returned to the Commission for Social Care Inspection as feedback from service users, service users relatives, care managers and a General Practitioner. Records examined included service user plans care manager needs assessments and risk assessments, medication records, complaints, staffing records, health and safety and fire records. Requirements and recommendations from the previous inspection were also discussed with the home manager and the registered provider. What the service does well: What has improved since the last inspection? The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 6 The home has met the majority of the requirements set by the Commission for Social Care Inspection at the last inspection. The home is working towards meeting those outstanding. The homes administration system has improved though a great deal of information is still hand written. Information provided to prospective service users by the home has improved. Since the last inspection double glazing windows have been installed in the lounge and a new settee purchased. One service user has had his bedroom redecorated. A new door and double-glazing windows have been installed in the lobby area. A new garden fence has been built and the office has been redecorated. A new medication storage cabinet has also been installed since the last inspection. What they could do better: The home needs to have a registered manager. Service users Person Centred Plans need to be reviewed so that people important in to the service user are able to contribute to the Person Centred Planning process. The new service user brought a Person Centred Plan from his previous placement, given that he is now living in a different environment under different circumstances the Plan needs to be reviewed. Service user meetings need to be increased so that the service users are offered opportunities to participate in the day-to-day running of the home. Staff should be encouraged and supported to achieve appropriate qualifications in care. Although the homes administration system has improved a lot of information is still hand written. The administration system could be further improved if the registered provider purchased a computer for the home and trained staff to use it. As a result of this inspection there are seven requirements and seven recommendations. The inspector would like to thank the service users, the staff and management of the home and all of those who provided feedback for their support in the inspection process. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 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. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4. One new service user has moved to the home since the last inspection, he had the opportunity to visit the home prior to moving in. Information provided to prospective service users by the home has improved. EVIDENCE: A needs assessment was carried out by the service users care manager prior to the service user moving to the home. There was a transition programme to support him to move from his previous placement to the home. This involved the service user, the home, the care manager, service users family and the service users advocate. A follow up transition meeting took place in February 2004. Minutes were taken by the acting home manager at the new service users placement review carried out on the 20th April 2005, this review was attended by the service users care manager, family, advocate, the acting home manager and the deputy manager. The acting home manager said that the care manager would send a copy of the placement review to the home. A requirement set at the last inspection that the registered manager devises a Service Users Guide using the National Minimum Standards Regulation 5 as guidance has been met. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 10 A requirement set at the last inspection that the registered manager ensure that a service user has a full care manager needs assessment carried out by the placing authority has been met. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9. All service users have Person Centred Plans however these have been completed by key-workers involving the service user only. They need to be reviewed so that people important in to the service user are able to contribute to the Person Centred Planning process. The new service user brought a Person Centred Plan from his previous placement, given that he is now living in a different environment under different circumstances the Plan needs to be reviewed. Service user meetings should be increased so that the service users are offered opportunities to participate in the day-to-day running of the home. EVIDENCE: Since the new service user has moved to the home he has been registered with a local General Practitioner, Chiropodist, Opticians and Dentist. His General Practitioner has also referred the service user to a dietician. A recommendation has been set that the home keep a record of the new service users dietary intake and produces this information to the dietician. The duty community nurse from the Croydon Learning Disability team also completed a Health Needs assessment for the new service user on the 25/04/05 the home is awaiting his report. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 12 The new service user has a Changing Days that he brought from his previous placement. This plan contains comprehensive information about the service user and his care needs including a communication profile. The acting home manager said that the home was using the information contained in the plan to support the service user. Given that the service user is now living in a different environment under different circumstances the Person Centred Plan needs to be reviewed. The home manager must ensure that new service users Changing Days Person Centred Plan is reviewed and that people i.e. service users relatives, advocates, care managers and appropriate others are invited to attend the review. Comment cards returned by two care managers indicate that they are satisfied with the overall care provided to the service users that they had placed at the home. A requirement set at the last inspection that the registered manager ensures risk assessments are regularly monitored and reviewed at least every six months. There was evidence that all service users now have risk assessments completed and that these are reviewed on a regular basis. The service users risk assessments will be reviewed under Keeping Safe section in the Changing Days Person Centred Plan. A requirement set at the last inspection that the registered manager ensures that the home completes individual service user Person Centred Plans and ensures that these are reviewed on a regular six-monthly basis has been partially met. Person Centred Plans have been completed by key-workers involving the service user only. Information gathered from these meetings has been incorporated into the Changing Days Person Centred Plan, however the home must ensure that these Person Centred Plans are reviewed and that people i.e. service users relatives, advocates, care managers and appropriate others are invited to attend the review. The acting home manager said that he is in the process of developing a pictorial communication system for the new service user. This will include pictures of places were the service user like to go i.e. cinema, Church and local cafes etc. The acting home manager is also developing a pictorial communication system for food that the service user likes. There were minutes of service user meetings held at the home. These appear to have been held on a monthly basis last year, all but one was written in shorthand, not easy to understand unless you can read shorthand, and stored in a file. There was evidence that only one service user meeting took place on the 29th of March this year. A recommendation has been set that the home offer the service users opportunities to participate in the day to day running of the home and that service user meetings are held on a regular basis. The The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 13 inspector enquired if the service users would invite him to part of one of their meetings, the acting home manager agreed that he would consult with the service users and get back to the inspector. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 and 17. Opportunities for service users to attend daytime activities and social activities are generally good. The home is developing opportunities to support the new service user in the community and to attend day services. EVIDENCE: The registered provider and the acting home manager explained that some service users enjoyed using public transport however she plans to purchase transport for the home. Service users attend various day centres, one service user attends Waylands day centre five days per week, one service user attends JMC day centre five days per week, one service user attends an art therapy class once a week at Geoffrey Harris House. The care manager referred the new service user to Geoffrey Harris House and the manager of the day centre has carried out assessments. A member of staff said that service users also attend the Gateway Club every Thursday and occasionally attend Debbie’s Club when they are invited. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 15 The acting home manager said that service users frequent cafes, restaurants, pubs, barbers and shops in the local community. On the day of the inspection two service users wet into Croydon on a shopping trip. The new service user has attended Church with another service user supported by one member of staff. The acting home manager explained that the new service user sometimes wishes to leave when the other service user wishes to stay. A recommendation has been set that the new service user be supported to Church on a one to one basis so that if he wishes to leave he can do so without disturbing the other service user. Service user weekly activity plans start on Monday and finish on Friday. A recommendation has been set that service user weekly activity plans be completed from Monday through to Sunday. The acting home manager explained that service users get up at different times in the mornings to prepare for the day, service users have breakfast at different times and leave the home at different times in the morning. Some service users choose to get up later to have breakfast. However the acting home manager explained that all service users sit down together at the dining table for their evening meal. One service user has regular visits from his sister and her husband every two months and occasionally visits them in Dorset. One service user who lost his mother two years ago is being supported to keep in contact with his remaining family. One service user was once married and has four children. The service users family do not wish to keep in contact with him, the acting home manager explained that the service user is coping well with the situation and staff deal with this issue in a sensitive and respectful manner. The new service user has regular contact with his family. One relatives comment card returned to the Commission for Social Care Inspection stated that “ I feel privileged that my brother has been placed in such a superior home with such lovely people, I find the carers at The Chestnuts to be very kind considerate and really caring people, they have always given myself and my brother such consideration, being approachable at all times. They have kept me informed throughout his stay at the home and their excellence cannot be faulted. My brother always appears happy and contented and this is of course is a tremendous relief on my part”. Other comment cards returned by relatives were positive as were cards returned by a General Practitioner and two care managers. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20. Arrangements made for the health care needs of the service users is good and the home has the support of the local pharmacist for advice on medication. EVIDENCE: None of the service users at the home self medicate. The home employs the Boots blister pack dispensing system. The acting home manager explained that the home has a good working relationship with the local pharmacist and he regularly audits the medication in the home. A new medication storage cabinet has been installed since the last inspection. There is a very low staff turnover rate at the home, which helps to ensure continuity of care for the service users. The new service user has been registered with a local General Practitioner, Chiropodist, Opticians, Dentist, been referred to a dietician and the duty community nurse from the Croydon Learning Disability team has completed a Health Needs assessment. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has an appropriate complaints procedure. The home has a copy of Croydon Adult Protection Procedure that is used in conjunction with the homes own abuse policy. EVIDENCE: The complaints procedure was observed in large print for the benefit of the service users. The complaints procedure has been completed in widget for the benefit of the new service user. The service users advocate has raised some concerns with the management of the home, care managers and the Commission for Social Care Inspection. These concerns were discussed with the registered provider and the acting home manager on the day of the inspection. A recommendation has been set that the home records any concerns directed to the home in a concerns and complaints book. This book should indicate the nature of the concern/complaint, action taken by the home to address the concern/complaint and the outcome of the concern/complaint. The home has a copy of Croydon Adult Protection Procedure; this is used in conjunction with the homes own abuse policy. The home has a Whistle Blowing policy. One of the relatives comment cards returned to the Commission for Social Care Inspection as feedback indicated that they were not aware of the homes complaints procedures. A recommendation has been set that the registered provider send a copy of the homes complaints procedures to all of the service users relatives. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, A number of improvements have been made to the home since the last inspection, service users bedrooms appeared to be personalised to the service users individual taste. EVIDENCE: Since the last inspection double glazing windows have been installed in the lounge and a new settee purchased. One service user has had his bedroom redecorated. A new door and double-glazing windows have been installed in the lobby area. A new garden fence has been built and the office has been redecorated. A new medication storage cabinet has also been installed since the last inspection. The home is well decorated and in good condition, a number of miner repairs need attention. The registered provider stated that she would enlist the support of a handyman to complete the repairs. These will be examined at the next inspection. The communal areas are a good size and sufficient for the number of service users. There is a large garden, which has a patio area by the house and a vegetable patch/allotment at the rear of the garden with a greenhouse. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 19 None of the service users smoke and there is now a non-smoking policy at the home but visitors can smoke in the garden. Service users said they liked their rooms. Bedrooms appeared to be personalised to the service users individual taste. All bedrooms have wash hand basins. There is a first floor bathroom and a second floor shower room. There appears to be sufficient bathing and toilet facilities to meet the needs of the service users. The acting home manager stated that he had programme of redecoration for the home but could not produce this on the day of the inspection. A recommendation has been set that the home manager forward a copy of the homes redecoration programme to the Commission for Social Care Inspection. The home was clean, tidy and free of odours. The home has Health and Safety procedures. COSHH materials are regularly reviewed. Service users clean their own rooms with the support of the staff. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 34. The home has a committed and well-established staff team that have worked together for a number of years, there has been very little staff turnover and this has been of great benefit for the service users, providing stability and consistency. Staff should be encouraged and supported to achieve appropriate qualifications in care. All members of staff have applied for Criminal Records Bureau Checks however the home is awaiting these checks being returned to the home. EVIDENCE: The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 21 The home has a committed and well-established staff team that have worked together for a number of years, there has been very little staff turnover. This has been of great benefit for the service users, providing stability and consistency while dealing with service users individual programmes and likes and dislikes. A requirement set at the last inspection that the registered manager write to the Commission for Social Care Inspection detailing how the home plans to meet the National Minimum Standards of 50 of the staff team with NVQ level 2 or above by 2005. The registered provider explained that the staff team have resisted opportunities to complete NVQ because they would have to go to college to complete the course. The registered provider agreed to contact the NVQ centre for advice and discuss this again with staff at the next team meeting. The registered provider write to the Commission for Social Care Inspection detailing how the home plans to meet the National Minimum Standards of 50 of the staff team with NVQ level 2 or above by 2005. A requirement set at the last inspection that the registered manager must ensure that the managers, the owner and all staff employed in the home complete Criminal Record Bureau Checks and inform the Commission for Social Care Inspection when this is completed. The acting home manager stated that the home is awaiting completed Criminal Records Bureau Checks being returned to the home. All members of staff have applied for Criminal Records Bureau Checks. The registered provider must write to the Commission for Social Care Inspection informing them when all staff Criminal Records Bureau Checks have been obtained. Staff files were examined, not all files had recent photographs and not all files had two written references. The registered provider must review the staff files and include all details as required in Schedule 2 of the National Minimum Standards. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 and 43. The registered manager has left and the registered provider is now planning to run the home. The acting home manager has worked hard to improve the homes recording and administration systems, however this could be further improved if the registered provider purchased a computer for the home and trained staff to use it. EVIDENCE: Since the last inspection the registered manager has left the home. The registered provider is now running the home but has recently had time off due to illness. During this time the registered provider wrote to the Commission for Social Care Inspection informing them that the home manager from another of the registered providers homes would be acting home manager for the home and that he would be supervised by her husband who is also a registered provider for the home. The registered provider must apply to the Commission for Social Care Inspection to be registered manger for the home. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 23 A requirement set at the last inspection that the registered provider complete monthly Regulation 26 visits, prepare a written report, sends a copy of this report to the Commission for Social Care Inspection and keep a record of these visits in the home. The registered provider had visited the home monthly and completed a health and safety audit. The registered provider must devise an appropriate format as discussed for Regulation 26 visits to the home, prepare a written report, send a copy of this report to the Commission for Social Care Inspection and keep a record of these visits in the home. The home had a Landlords Gas Safety Certificate 27/08/04, Legionella Testing Certificate 27/08/04, Environmental Health Visit 26/01/05 (this stated that very good standards are being maintained), Control of Substances Hazardous to Health assessment was carried out 10/02/05 and the Portable Appliance Test has been arranged for June 2005. The homes policies and procedures have been reviewed and updated. The acting home manager has worked hard to improve the homes recording and administration systems, however a great deal of information is still hand written. A recommendation has been set that the registered provider purchase a computer for the home and that staff is trained to use it. A copy of the homes accounts was provided for inspection. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Chestnuts Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 3 3 3 G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 25 No 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 6 Regulation 15(1) Requirement Timescale for action 31/07/05 2. 6 15(1) 3. 33 18(1)a The registered manager must ensure that new service users Changing Days Person Centred Plan is reviewed and that people i.e. service users relatives, advocates, care managers and appropriate others are invited to attend the review. The home must ensure that all 31/07/05 other service users Person Centred Plans are reviewed and that people i.e. service users relatives, advocates, care managers and appropriate others are invited to attend the review. The registered provider write to 31/07/05 the Commission for Social Care Inspection detailing how the home plans to meet the National Minimum Standards of 50 of the staff team with NVQ level 2 or above by 2005. The registered provider must write to the Commission for Social Care Inspection informing them when all staff Criminal Records Bureau Checks have been obtained. The registered provider must review the staff files and include 4. 34 19(1)b As stated. 5. 34 19(1)b 31/07/05 Page 26 The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 6. 37 8(1) a 7. 39 26(1) all details as required in Schedule 2 of the National Minimum Standards. The registered provider must 31/07/05 apply to the Commission for Social Care Inspection to be registered manger for the home. The registered provider must 31/07/05 devise an appropriate format as discussed for Regulation 26 visits to the home, prepare a written report, send a copy of this report to the Commission for Social Care Inspection and keep a record of these visits in the home. 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. 3. 4. 5. Refer to Standard 6 8 16 12 22 Good Practice Recommendations The home should keep a record of the new service users dietary intake and produce this information to the dietician. The home should offer service users opportunities to participate in the day to day running of the home and service user meetings should held on a regular basis. The new service user should be supported to Church on a one to one basis so that if he wishes to leave he can do so without disturbing the other service user. Service user weekly activity plans should be completed from Monday through to Sunday. The home should record any concerns directed to the home in a concerns and complaints book. This book should indicate the nature of the concern/complaint, action taken by the home to address the concern/complaint and the outcome of the concern/complaint. The registered provider should send a copy of the homes complaints procedures to all of the service users relatives. The home manager should forward a copy of the homes redecoration programme to the Commission for Social Care Inspection. The registered provider should purchase a computer for G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 27 6. 7. 8. 22 24 37 The Chestnuts the home and that staff is trained to use it. The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor, Grosvenor House 125 High Street, Croydon CR0 9XP 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 The Chestnuts G53-G53 S25846 TheChestnuts V193370 090505 Stage 0.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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