Inspection on 29/07/05 for Cheverels Care Home

This inspection was carried out on 29th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cheverels Care Home 15/09/06

Cheverels Care Home 23/11/05

Cheverels Care Home 20/12/04

Cheverels Care Home 13/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

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

CARE HOMES FOR OLDER PEOPLE Cheverels Care Home 52 Dorchester Road Maiden Newton Dorchester DT2 0BE Lead Inspector Rosie Brown Unannounced 29 July 2005 10:30 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 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. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cheverels Care Home Address 52 Dorchester Road, Maiden Newton, Dorchester, Dorset, DT2 0BE 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) 01300 320348 01300 320348 Altogether Care LLP Mrs Martina Goble Care Home with Nursing 19 Category(ies) of DE(E) - 19 registration, with number PD(E) - 19 of places MD(E) - 19 Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The Registered Manager will attend training (as identified to the Commission for Social Care Inspection) in the protection of vulnerable adults by the 1st June 2005. The Registered Manager will attend training (as identified to the Commission for Social Care Inspection) in holistic dementia care by the 1st June 2005. Date of last inspection 20 December 2004 Brief Description of the Service: Cheverels Care Home is registered to provide nursing care to a maximimum of 19 elderly people with mental confusion and physical disability. On the day of the inspection there were 18 service users accommodated in the home. The home is established in a converted 16th century coaching house which is situated in the middle of Maiden Newton. It is close to all local amenities, post office, public house, church and petrol station. The accommodation is available over two floors with the first floor access by passenger lift. The second floor provides two staff offices and a WC and accommodation for staff. There is a small private garden with raised borders at the side of the house and a parking area for visitors use. The Registered Individual (RI) is Mr Peter Cotterill on behalf of Altogether Care LLP, the Registered Manager is Mrs Martina Goble. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 29th July 2005 between the hours of 10:30am and 4:30pm. The purpose of the visit was to review the progress with requirements and best practice recommendations from previous inspections. Information was gathered through discussion with the manager, Mr Cotterilll, five service users and the staff on duty at the time. The inspector used observation skills to access some of the findings. The communal areas and a selection of residents’ rooms were seen during the visit, certain records were examined and the home’s policies gave further information. What the service does well: The pre-admission assessments of service users needs and the home’s care planning achieves a good standard. A registered nurse is on duty at all times and takes responsibility for the medication to ensure that medicines are administered in accordance with the prescribed instructions. The home’s policy concerning the protection of vulnerable adults has been updated and staff have signed to acknowledge they have read and understood the associated procedures. The manager and deputy have undertaken the local adult protection training concerning ‘No Secrets’. Since the previous inspection ten members of staff have been supplied with adult protection training and regular supervision sessions are being supplied to all staff. There is a registered manager in post and she has recently achieved the registered managers certificated award. The home achieves a warm and friendly, relaxed environment and the fabric and furnishings of rooms is good. One service user said ‘this is my home, it’s a lovely home’. The home was found to be very clean on the day of the unannounced visit. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The incorrect information identified in the home’s statement of purpose and guide must be updated so that accurate information is supplied to service users and their representatives. The central heating radiators are not covered or protected and individual riskassessments concerning each person’s vulnerability to hot surface temperatures have been drawn up by the manager. A programme of covering and protecting the radiators must be planned to ensure that service users are safe from accidental harm; commencing with those rooms where remedial action has been identified. The registered persons should consider how to provide a comfortable place where visitors can meet with service users in private particularly because there several shared bedrooms in the home. The home’s call system is old and needs to be replaced with a system that is easy to use. Service users must be able to call for assistance from their bed or armchair when in their room and when in the communal areas of the home, e.g. lounge and dining room. The registered persons must identify a proper area for the storage of incontinence products and items of equipment that are not in continual use: on the day of the inspection such items were inappropriately stored in one of the homes bathrooms thereby negating its use. The RI must provide the Commission with Regulation 26 reports of his or his representative’s monthly visits to demonstrate that the management business team is aware of the way the home is operating and actively seeking the views of service users and their relatives or visitors. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 7 The registered persons must ensure that Regulation 37 reports are sent to the Commission following any untoward accidents or incidents to evidence how these occurrences are dealt with and to ensure the safety of vulnerable service users. The registered persons must consult with the Fire Safety Officer to establish the most suitable door closure to be fitted onto the staff rooms/office doors; when fire doors are propped or wedged open they compromise the fire safety precautions in the home (as was the case on the morning of this unannounced inspection). Also the need for an extractor fan and/or air conditioning must also be discussed/considered to ensure these rooms are comfortable to work in. 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. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 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 standard(s) 1, 3, and 6 The home has a statement of purpose and guide compiled in a colourful wallet and this is supplied to prospective service users and their representative on request. This information enables the reader to make an informed choice about the facilities and care supplied by the home although a small part of the information is out of date. The manager undertakes a comprehensive pre admission assessment of each service user’s needs prior to admission to ensure their needs can be met by the home. The home does not provide intermediate care. EVIDENCE: The manager gave a copy of the home’s statement of purpose and guide to the inspector. The information is supplied in a wallet and also includes; a thank you for your enquiry letter from the manager, a location map, photograph and description of the house, the home’s philosophy of care, details about meals and mealtimes and the policies on making complaints and service users’ rights. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 10 Since becoming registered earlier this year the manager has completed the Registered Managers Award and Dementia Care Training and the statement of purpose should be updated to reflect this improvement. Although the coloured photograph and location map is useful some of the information included is out of date as it refers to the former resident proprietors and the former registration authority. Care records evidenced that the manager routinely undertakes pre admission assessments of each prospective service user’s care needs prior to admission. The details obtained included all recommended topics, family history and personal profiles and important information from associated care professionals. The residents who spoke with the inspector confirmed they are happy in the home but because of memory and communication difficulties were unable to confirm or recollect their admission into the home. Cheverels does not offer intermediate care. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 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 standard(s) 7, 8 and 9 The care needs of each individual are included in a care plan but they do not include sufficient information about the service user’s wishes regarding care when dying and upon death. Records showed evidence of representative’s involvement in decisions made about care provision, care planning, care related risk-assessments, and protection. Residents’ health needs are monitored and responded to appropriately with support from community services. The home’s medication policy and procedures are always followed by staff to ensure the safe administration of service user’s medication and no further action was required to address previously identified requirements regarding the use of homely remedies. However, it was noted that on one or two occasions the record of administration (MAR) chart had not been signed staff to demonstrate if medicines had been administered or not. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 12 EVIDENCE: Care plans and care records for three residents were examined and included details of personal hygiene and wound care, elimination, nutrition and special diets, mobility, sleeping arrangements and patterns, communication, sensory needs, psychological needs, mental health issues, safety, social interaction and activities, health, foot care and oral hygiene. However, all care plans must include more information concerning the care and wishes of service users when they become critically ill or are dying. Care related risk-assessments were documented and included topics such as; nutrition, falls, wound care, social care, mobility, self neglect, the development of hypo or hyperglycaemic attack, short term memory problems and the use of bed rails. Care records evidenced that regular and appropriate contact is made with care professionals for further advice and guidance. It was noted that the Commission had not been informed as required of several untoward incidents and one accident when a service user was taken to the local A&E for treatment. The home is now keeping a record of incidents as well as accidents that occur. The home has a treatment room where the medicines trolley is stored the door to this room is locked. All service users’ medication is kept and managed by the home. The registered nurse in charge of each shift administers medication and holds the key to the drugs trolley controlled drugs cupboard and treatment room. When the medication administration record (MAR) charts were examined it was noted that on a minority of occasions the record had not been signed to evidence if the medication had been administered or not: this mainly related to prescribed medication given as and when required (prn). Since the previous inspection the RI has produced a policy and procedure concerned with the provision and administration of homely remedies, e.g. cough mixture. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 The home welcomes and encourages contact with friends and relatives/representatives although there is no separate private area where visitors can meet with service users. Service users are provided with three meals a day, the food is mainly home baked with the menu including residents’ favourite foods and requests. Special diets are catered for and nutrition supplements supplied as appropriate. EVIDENCE: The home’s statement of purpose and guide states; ‘ service users are given help to maintain the links they wish to retain with their families and friends’ and ‘friends and relatives are welcome at any time convenient to the service user and to become involved in daily routines and activities. One service user confirmed that his wife has lunch with him in the home while staff said that they also go to the pub across the road from the home. Care records for this person demonstrated that his wife visits weekly. Other service users’ visitors’ records and the home’s visitor’s book detail that visitor’s call into the home on a regular basis. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 14 There is no separate visitors room/area and this matter must be resolved because although visitors can be received in a service user’s room six of these are shared. The home uses a weekly menu, which incorporates seasonal vegetables and fruit. The daily menu offers a choice at each meal and specific likes and dislikes are recorded into the service user’s care plans: some service users are assisted to eat while others are monitored either because they would not eat enough or would eat too much food if unsupervised. The inspector was invited to take lunch with three service users in the dining room and it was noted that meals are taken in two sittings to ensure that all service users receive the attention and assistance they need. Meals are eaten in the dining room or in service user’s rooms and special diets are provided. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a complaints policy and procedure, which enables service users and their representatives/advocate to raise concerns. EVIDENCE: The home has a complaints procedure, which is supplied to all prospective service users, their relatives or representatives during admission for future reference and use. The home keeps a complaints book and management (Altogether Care) take all complaints seriously when received: no complaints have been received about the home since the previous inspection. Because service users’ communication skills are limited it was difficult to establish from them how they could make a complaint if they wanted to but observed pleasant and helpful interactions between staff and service users. However the home has a key worker system in place and policy concerned with individual rights. Prior to this inspection the Commission received a telephone call from a service user’s long-term elderly friend who does not live locally. The visitor and his wife had recently experienced a problem when trying to visit unexpectedly; on arrival they were told by staff that they could not see the service user because family were visiting, apparently they called back on another occasion and did see the service user. The manager agreed to contact the visitor to establish what had happened and to seek a resolution thus preventing recurrence. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19 and 26 The home is clean throughout, attractively decorated and comfortably furnished creating a homely atmosphere for service users. However, the call facility is old and difficult to use and central heating radiators are not guarded therefore the environment is not safe and this places service users at risk of injury. EVIDENCE: The home has a separate lounge and dining room both are pleasantly decorated and comfortably furnished. Bedrooms are situated on the ground and first floor of the home and the first floor is accessed by the main staircase or passenger lift. There are seven single bedrooms and six shared bedrooms: five single rooms and one of the shared rooms have en-suite facilities. Four bedrooms are under the recommended size: two single and two doubles, and this means that staff have to move furniture around when specific equipment/aids are used. The manager explained that the owners are planning to develop/extend the home some time in the future but in the meantime this continues to be a problem for staff and Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 17 service users. The majority of the bedrooms viewed had been personalised with service users’ possessions and individual inventories of belongings brought into the home are kept. The home’s call facility is old with box style handsets that were damaged with press buttons indented; these must be difficult for elderly frail and confused service users to use. An action plan detailing how and when this facility in the home will be upgraded must be forwarded to the Commission. There is one WC situated on the ground floor and two bathrooms with toilets on the first floor. On the day of the inspection one bathroom was being used to store incontinence pads and other items of equipment, it was evident that this bathroom is rarely used and the manager explained it is not used because the bath seat is not suitable for the needs of the current service user group. The other assisted is well used but the bath enamel is chipped and this remains a possible source of cross infection. Radiators in bedrooms and communal areas are not guarded. Although riskassessments have been documented regarding each service user’s vulnerability to hot surface temperatures and burns this matter must be resolved to ensure that service users are not at risk of accidental harm. The second floor of the home is used for staff accommodation and there are two staff offices. The doors to both staff offices were propped open when the inspector arrived at the home. Although the chair propping open the staff office door was removed as was the wedge used to keep the manager’s office door open the wedge was later replaced. It was evident that this situation must be resolved as propping open fire doors compromises the fire safety precautions in the home and therefore puts staff and service users’ health and safety at risk. The fire safety officer must be consulted to establish the most suitable type of door closure to be fitted on the office doors so that they can be left safely in the open position. The need for an extractor fan in the offices or an air conditioning unit must also be discussed. The most recent visit by the Environmental Health Officer (EHO) identified two matters requiring attention in relation to the home’s kitchen: the extractor canopy filter has been cleaned as has the floor to the dry store room. It was also recommended that records of temperature checks of hot and chilled foods be kept and these were shown to the inspector. Although the EHO highlighted a concern that chickens were being kept at the premises none were seen on the day of the inspection. The home’s laundry is currently established in an outbuilding and the previous inspection report identified that when staff are undertaking laundry tasks, particularly at night they are not easily contacted and available for service user assistance if necessary. The manager stated that this matter has been resolved by providing a mobile communication aid to staff but the laundry does not Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 18 have a call- board that receives or identifies calls for assistance. This matter must be properly resolved for example a daily laundry assistant could be appointed, this would minimise the amount of time the night staff need to be in the laundry. The staff rota evidences that a domestic assistant is employed for 38 hrs per week and on the day of the inspection the home was clean with no unpleasant odours apparent. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The staff rota confirmed that a registered nurse is on duty 24hrs each day supported by health care assistants and some domestic staff. A staff training programme including NVQ2 training is now in place to ensure that they have the skills necessary to care for service users who are mentally frail. The manager uses a standard company staff recruitment and employment procedure. However, when new staff commence working in the home without their CRB disclosure satisfactorily returned and no POVAFIRST check this puts service users at potential risk of harm. EVIDENCE: The manager supplied a copy of the staff training programme this includes a supervised induction process that meets National Training Organisation (NTO) specifications. Additionally, she explained that other topics relevant to service users care needs are being provided, e.g. managing challenging behaviours and the manager said this aspect of training is gradually being developed. The staff team comprises of registered nurses and health care assistants five have NVQ 3 qualifications while a further four are enrolled on NVQ training courses. The manager works each weekday and her hours total approximately 42hrs and she is additional to the staff team. Other staff employed include; a domestic, a kitchen assistant, a maintenance worker and a cook/chef. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 20 The recruitment record for the most recently employed member of care staff was examined and the inspector met this person who was leaving work in the home due to family commitments. The majority of relevant references and checks were undertaken before employment started but it was noted they had commenced working in the home before the CRB disclosure check had been satisfactorily returned, without a POVAFIRST and not in an additional capacity. Although the manager said supervision had taken place there were no records to support this. There was written evidence that regular supervision of all staff is now taking place and this includes nurses clinical supervision. Staff on duty were observed to be polite, respectful and patient with service users. One service user said to the manager, ‘I know you don’t I? you are kind to me’ while another commented, ‘they are kind in here’. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37 and 38 The registered manager is trained and experienced and is supported by regular visits from the RI and Chief Executive of the company to ensure that service users are properly cared for. The management have set up policies and procedures to ensure that staff are supplied with guidance regarding the expected practices associated with service users care and these are subject to annual review. The management have yet to ensure that the all health and safety aspects of service users’ care is being promoted. EVIDENCE: The manager has achieved NVQ management training and recent training in Dementia Care this was evidenced by certificates supplied by the educating bodies following training. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 22 The home’s current registration certificate has two conditions regarding the registered managers training: a new certificate reflecting that the conditions are met will be issued by the Commission in the near future. Mr Cotterilll has been nominated to undertake Regulation 26 visits and the production of the reports of theses visits. At the time of the inspection no reports concerning these visits although Mr Cotterill said during the inspection that he was undertaking a visit on the day. Staff are supplied with induction training and mandatory training that meets NTO specifications and the manager is developing the training provision in the home to incorporate other subjects. The home keeps records of accidents and incidents that occur but it was noted that Regulation 37 reports of untoward accidents and incidents are not currently being sent to the Commission as required. The company has set up a Health & Safety manual for staff reference and guidance and this incorporates all aspects of associated legislation. Records of fire safety checks and the servicing of equipment were not examined during this inspection. The propping open of fire doors to staff offices on the second floor of the home has been referred to earlier in this report and must be ceased. The home’s call system must be improved and a programme of covering or guarding radiators in the home must be commenced where radiators are exposed and where service users are likely to inadvertently hold onto them or fall against them to ensure that service users are safe from harm. Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x 2 2 Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 24 Yes 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 OP 1 Regulation Schedule 1 Requirement The location information leaflet in the homes statement of purpose and guide must be updated to provide accurate information. Care plans must include more detail regarding each service users wishes/needs for their care when dying and in the event of death. The MAR charts must be signed by staff to demonstrate if medicines have been administered or not. All radiators must be guarded or have guaranteed low temperature surfaces. A action plan detailing how this situation will be resolved must be supplied to the Commission. (previous timescale of 1.2.05. not met although risk-assessments have been drawn up). The registered persons must ensure that there are adequate storage areas for incontinence supplies and other items of equipment. The second bathroom must be cleared of all items inappropriately stored in the Timescale for action 31.10.05 2. OP7 15 (1) 31.10.05 3. OP9 13 (2) 30.9.05 4. OP19 13 (4) 31.10.05 5. OP19 23 (2) (l) 31.10.05 6. OP19 23 (2) (j) 31.10.05 Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 25 7. OP19 23 (2) (m) 8. OP19 13 (4) & 23 (5) room and action taken to identify and supply a more suitable bathing aid. Measures must be taken to ensure that the damage to the bath enamel in the assisted bathroom does not promote cross infection. The old call system must be 31.10.05 replaced with a more suitable system that suits the needs of service users and be available for use in all communal rooms. An action plan concerning how this matter will be resolved must be supplied to the Commision. Fire doors must not be propped 31.10.05 open. The registered persons must consult with the Fire Safety Officer to ensure this situation does not continue: see details in report. 9. 10. 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 OP13 Good Practice Recommendations The registered persons should consider how to provide a comfortable place where visitors can meet with service users in private particularly because there a several shared bedrooms in the home. The registered person or his delgate should carry out a visit to the home at least once a month and send a copy report of this visit to the Commission. (previous timescale 20.3.05 not met) A report of the July visit was received by the inspector on 12.8.05. The registered persons should inform the Commission without delay of any untoward accident or incident that afffects the well being of a service user. A Regulation 37 notification was received from the home following an incident on 4.8.05. D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 26 2. OP37 3. OP37 Cheverels Care Home Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF 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 Cheverels Care Home D55 S43799 Cheverels V229938 290705 Stage 4.doc Version 1.30 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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