Inspection on 08/05/07 for Chiltern Cheshire Home

This inspection was carried out on 8th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chiltern Cheshire Home 13/02/06

Chiltern Cheshire Home 01/12/05

Chiltern Cheshire Home 23/11/04

Chiltern Cheshire Home 22/09/04

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

CARE HOME ADULTS 18-65 Chiltern Cheshire Home Packhorse Road Gerrards Cross Bucks SL9 8JT Lead Inspector Joan Browne Unannounced Inspection 8th May 2007 11:30 Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chiltern Cheshire Home Address Packhorse Road Gerrards Cross Bucks SL9 8JT 01753 480950 01753 480951 hanne.abildgaard@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Ms Hanne Abildgaard Care Home 22 Category(ies) of Physical disability (0), Physical disability over 65 registration, with number years of age (0) of places Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No persons over the age of 65 to be admitted. Date of last inspection 13th February 2006 Brief Description of the Service: Chiltern Cheshire is a purpose built home situated in Gerrards Cross. The home provides care for 22 adults who have a physical disability. Personal care and support is provided for both men and women between the ages of 18 and 65 yrs old. The home is located in close proximity to the town centre where all local facilities can be found. Service users utilise these services and the facilities of the nearby towns of High Wycombe, Slough and Uxbridge. The current weekly fees range from £868.00-£1055.42. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced ‘Key Inspection of the service, which took place on 8 May 2007. Prior to the fieldwork visit previous information about the home was reviewed and the outcome of previous inspections noted. The inspection consisted of the case tracking of two service users from their original contact with the home to the care that they are now receiving. Discussions took place with other service users, staff members and the manager. Staff practice was observed, care documentation and records were examined and a tour of the building was conducted. Comment cards were received from four service users, two general practitioners and four staff members. Overall, comments made were very positive. Service users were happy with the care provision and were complimentary about the manager and the staff team. From evidence seen and comments received, it is considered that this service meets service users’ cultural, religious and diverse needs. The inspection process highlights the home to be one that is well run with high standards of care. The inspector would like to thank the manager, service users and staff for their hospitality and time during the inspection. What the service does well: The home ensures that the needs of prospective people to use the service are assessed prior to admission to ensure that identified needs would be fully met. The home ensures that people who use the service are involved in planning the care they receive. Clear and concise care plans were in place to support this. The home ensures that the activities provided meet the lifestyle of people who use the service. The home ensures that people who use the service maintain links with family, friends and the local community. The home ensures that personal and healthcare needs are attended to in the way people prefer. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 6 The home has a complaints procedure in place to ensure that people’s views are listened to and acted upon. The layout and design of the home enables people to live in a safe and maintained environment. People who use the service benefit from a well run home, which looks after their interests. The management team is continuously working to improve the service for service users, focussing on equality and diversity issues. What has improved since the last inspection? What they could do better: The home should ensure that people who self-medicate have the appropriate risk assessments in place to ensure that any identified risks are eliminated or minimised. The home should ensure that it complies with the Royal Pharmaceutical best practice guidelines by ensuring that medicines to be administered to people who use the service have a printed label with the individual’s name, strength of the medicine, dose and frequency. The home must comply with the current recruitment guidelines by ensuring that criminal record bureau (CRB) clearances are obtained when staff progress into a different care position. To comply with current regulations evidence must be available to confirm that PoVA first checks have been obtained for individuals before commencing employment. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 7 The home should ensure that the status of staff visas is available and current to ensure that individuals are fit to work and care for people who use the service. A recent photograph should be held on staff members’ files to confirm proof of identification. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Prospective people to use the service have a full comprehensive needs’ assessment before admission to ensure that the home would be able to meet all identified needs. EVIDENCE: The home’s assessment process was discussed with the manager. She confirmed that prospective residents receive a full comprehensive needs’ assessment before admission to ensure that the home is able to meet all identified needs. Prospective residents are invited to spend some time in the home to meet residents and the staff team. The home’s staff would also visit a prospective resident in his or her own home or in hospital. For residents funded by a placing authority, the home would obtain a copy of the care plan and summary of any assessment undertaken through care management before admission is considered. The home involves the prospective resident and their representative in all aspects of the assessment process. A three-month settling-in period is agreed which is kept under review. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are involved in decisions about their lives, and are able to plan the care and support they receive, which was detailed in the care plans seen. EVIDENCE: Case tracking highlighted that information recorded in the two care plans examined was detailed. They were person-centred and focussed on individual’s preferences, such as how personal care should be provided and by whom, their preferred time for rising and retiring and daily activity interests. Risk assessments were in place relating to moving and handling, skin integrity and nutrition. It was noted in one particular care plan that there was no risk assessment in place to support self-medicating. There was evidence that the plans were regularly reviewed and were signed by individuals to confirm their involvement in the process. Staff spoken to were familiar with the content of the care plans and it was evident that they were being used as working tools to ensure that care provided was personalised and of a high standard. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 11 The standard of recording in the daily log was satisfactory. However, scribbled out entries were noted, which is poor practice. Because the daily log sheets can be used in a court of law or in a complaints investigation, this practice should cease. Most residents spoken to said that they were able to make their own decisions, which staff respected. Details relating to personal decisions made were recorded in care plans seen. The home would support residents to access the services of an advocate if they wished to. There is an active residents’ committee. The group meets with the manager monthly and she updates them on matters relating to the environment, staffing and the provision of care. Some residents also assist the manager with the recruitment and selection of staff. The manager said that interviews are carried out face-to-face as well as via the telephone, which is known as a conference call. Residents are supported to lead the life they choose to have, and are encouraged to take risks as part of promoting and maximising their independence, with the appropriate risk assessments in place. It was noted that some residents were able to go on shopping trips unescorted to the local shopping centre and to the bank or building society. Others enjoyed participating in outside activities such as sailing, photography and swimming. It was noted that eighteen residents handle their own financial affairs. Two were subject to power of attorney and one subject to guardianship. The manager said that Social Services regularly audit the individual who is subject to guardianship finances and the records have always been found to be in good order. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that the social and recreational activities provided meet the lifestyles of the people who use the service. They are encouraged to maintain links with family and the local community. Meals provided meet their varying dietary needs. EVIDENCE: There were no residents undertaking further education or distance learning studies. The home employs two activity organisers who facilitate daily activities of residents’ choice. The activities provided are kept under review and are changed to meet individual’s changing needs, choices and wishes. It was noted that the activity room was recently refurbished and looked bright and welcoming. The kitchen area was equipped with a cooker, sink and tables that can be adjusted to the height of residents’ wheelchairs, which allows residents to be more independent. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 13 A local college donated several computers to the home. The computers have internet facility and residents spoken to said that they enjoyed participating in the information technology activity. Residents and representatives who responded to the Commission’s comment cards said that there were ‘always’ or ‘usually’ activities arranged in the home. The following additional comments were noted: ‘There are plenty of activities provided.’ Residents are seen as part of the local community and are able to access local facilities such as shops, pubs, library, leisure centres and places of worship. Residents said that the local bakery often donates cakes and bread to the home. It was evident that the home maintains a neighbourly relationship with the community. Local people act as volunteers and escort residents on outings and other social activities outside the home. The home also has close links with a local company in the area who offer support to residents. The home’s staff support residents to maintain links with their family and friends. Residents are able to choose who they wish to see and when, and can have visitors in their rooms in private. There are no restrictions on visiting and residents have unlimited access to the grounds. Those residents who wish to develop or maintain intimate personal relationships with people of their choice are able to do so. Staff are expected to knock on residents’ bedroom doors and wait for a reply before entering. The home ensures that residents are provided with a key to their bedroom. However, some residents choose not to have one. Staff ensure that residents’ letters are not opened without their agreement. Their preferred term of address was recorded in care plans seen. The home provides a six-week menu with a variety of choices to meet residents’ varying dietary needs. Residents can choose to eat in their bedrooms or in the dining room. The manager said that the chef consults with residents on a regular basis to discuss choices on the menu. An alternative choice would be provided if individuals did not like what was on the menu. Residents spoken to confirmed that the food was good and mealtimes were flexible and relaxed. A sensitive issue relating to a particular resident’s preference and wishes was discussed with the manager. She has agreed to review the individual’s care plan to ensure that it reflects the individual’s preference. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service are supported with their personal and healthcare needs in the way they prefer. However, some inconsistency in staff medication practice has the potential to put residents at risk. EVIDENCE: Case tracking identified that residents were receiving personal care in accordance with their preferences and wishes. Supporting plans seen reflected how individuals wished to be moved and handled and by whom. Bedrooms seen had the appropriate aids and adaptation to assist with safe moving and handling and to promote individual’s independence. Residents are encouraged by staff to look after their appearance and attire and select their hairstyles. Additional specialist support is available in the home from the physiotherapists and the activity co-ordinators. The occupational therapist, speech therapist, district nurse and continence adviser, if required, also provide external specialist support. Residents who cannot easily communicate their needs are provided with aids such as liberator and pictures to assist them. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 15 Residents’ keyworkers support them to manage their healthcare needs. All residents were registered with a general practitioner who visits the home when required. They are also able to access the services of the community chiropodist as and when needed, and have regular dental and optical check-ups. Those experiencing incontinence problems can access the services of the continence adviser who will provide the necessary aids and equipment to improve and promote continence. The home promotes residents to be independent and individuals who have been assessed as being able to are encouraged and supported to do so. Case tracking identified that one particular resident who was self-medicating did not have the appropriate risk assessment in place. A recommendation is made in this report to ensure that risk assessments are in place for service users who self-medicate. There were no gaps noted on the medication administration record (MAR) sheets examined. However, scribbled-over entries were noted on a particular MAR sheet, which is poor practice and should cease. It was also noted that there was an unlabelled bottle of olive oil in use. To comply with the Royal Pharmaceutical Society best practice guidelines for a member of staff to administer a medicine, it must have a printed label with the resident’s name, strength of the medicine, dose and frequency. Controlled medication was stored in an appropriate cupboard and records and stock balances indicated that they were in order. On the day of the inspection a quality audit on the home’s medication process had taken place by a person from the organisation’s quality team. The manager said that the home had recently changed its medication provider. The new provider had provided training for those staff responsible for administering medication. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People who use the service were confident that their views were listened to and acted upon. There are policies and procedures in place to ensure that people who use the service are protected from any potential risk of harm or abuse. EVIDENCE: Information recorded on the pre-inspection questionnaire indicated that the home had not received any complaints about the service. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Information about the home’s complaints procedure is included in the service users’ guide, which was displayed in the front entrance of the home. Residents and representatives who responded to the Commission’s comment cards said that they were aware of how to make a complaint. Those spoken to during the inspection said that they were extremely satisfied with the service and felt safe and well supported. The Commission has not received any information concerning any suspicion or evidence of abuse or neglect made to the service since the last inspection. The home has policies and procedures regarding safeguarding adults, which are available to staff to give them guidance about what action should be taken. Staff spoken to were able to demonstrate what action should be taken if they suspected or witnessed an incident of abuse. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 17 Information submitted on the pre-inspection questionnaire indicated that staff had undertaken training in safeguarding vulnerable adults, which was ongoing. Most service users were managing their own finances and were provided with lockable storage space to store valuables and money. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The design and layout of the home enables people who use the service to live in a safe, clean, hygienic and homely environment. EVIDENCE: The premises are suitable for its stated purpose. It is accessible, safe and well maintained to meet residents’ individual and collective needs and comply with the current building regulations. On the day of the inspection the home was bright, clean and free from offensive odours. The grounds and garden were tidy and looked well maintained The manager said that there were records relating to the planned maintenance and renewal programme for the fabric and decoration of the premises. These were being reviewed to include more detailed information on work carried out. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 19 Bedrooms seen were clean and tidy with pictures and ornaments to reflect individual’s characters. Bathrooms and toilets were fitted with the appropriate aids and equipment to maximise independence. Information recorded on the pre-inspection questionnaire indicated that the requirements and recommendations from the recent fire officer and environmental health inspections had been acted on. The laundry room was situated away from where food is prepared and is equipped with washing machines with the specified programming ability to meet disinfection standards. The walls and floors were clean and free from dust. The sluice room was in a satisfactory condition. The area where clinical and general waste is stored was securely enclosed. Residents and representatives who responded to the Commission’s comment cards said that the home was ‘always’ fresh and clean. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Insufficient staffing numbers and poor recruitment practice have the potential to put people who use the service at risk. EVIDENCE: Residents and representatives who responded to the Commission’s comment cards said that the home was usually short of staff in the evenings and at the weekends. The staff rota on the day of the inspection reflected that there were six staff members covering the morning shift. This number was reduced to four staff members on the afternoon shift and two at night. The staffing rota was discussed with the manager who confirmed that the allocated staffing numbers should be seven staff in the morning, five in the afternoon and two at night. The home has been experiencing a high level of sickness absence, which has made it difficult to provide the appropriate level of staffing. It was noted that the home had recruited new staff members who were due to take up their appointments shortly, which should address the problem. Agency staff are used to cover absenteeism but residents and representatives felt that some of them lacked experience. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 21 The following additional comments were noted from respondents: ‘More care staff required especially in the afternoon’, ‘Agency staff called in to fill gaps do not appear to me to have the necessary aptitude or skills’, ‘Sometimes have difficulty in communicating with some staff’. The recruitment records for the four recently appointed staff members were examined. Shortfalls were identified in the home’s recruitment process. In all four files seen Criminal Record Bureau (CRB) clearances had been obtained. However, it was not evident that PoVA first checks had been obtained. As from 26 July 2004 the regulations required all staff to obtain a PoVA first check before commencing employment. Under current procedures this means applying for a Criminal Record Bureau (CRB) check and ensuring that a cross is placed in box Y4. In one particular file the status of the individual’s visa was not evident. It was noted that two staff members had been working with vulnerable adults previously. There was no written verification (so far as reasonably practicable) of the reason why the individuals ceased to work in that position. One staff member had been promoted into a senior position and a second was a temporary worker who had been offered a permanent night contract. Guidance stipulates that ‘staff employed prior to 26.07.04 do not need extended checks as long as they have an existing CRB check relevant to their post and as long as they remain in the same position. As the staff members’ positions had changed, new CRB clearances should have been obtained. A requirement to undertake the necessary checks when staff move into different care positions has been made within this report. There were no photographs noted on staff files examined to confirm proof of identity. It was noted that sixteen of the thirty-three care staff had achieved the national vocational qualification (NVQ) in Level 2 and 3 in direct care, thus ensuring that the home’s 50 target ratio had been achieved. All new staff undertake a structured induction programme and are shadowed by an experienced staff member until feeling confident. Information submitted on the pre-inspection questionnaire indicated that the home has an ongoing rolling programme of mandatory training in place. The manager confirmed that the home has a training and development plan. A designated person with responsibility for the home’s training and development programme was recently appointed to co-ordinate all training. Staff spoken to said that they regularly undertake updated mandatory training. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a well run home, which looks after their best interests. Health and safety records were in order and should indicate that people’s health and safety are protected. EVIDENCE: The manager has the required qualifications and experience to run the home. She holds the NVQ 4 and the Registered Manager’s Award certificate. A care supervisor and seven team leaders support the manager in the day-to-day operation of the home. Her overall responsibilities are to ensure that the aims and objectives of the home are achieved. Policies and procedures are implemented and staff have an understanding of their content. Residents have current care plans and contracts and they understand the terms and conditions of their occupancy. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 23 Residents and staff spoken to said that the manager was approachable and operates an open door policy. There were clear lines of accountability within the home and with any external management. It was noted that the management team was continuously working to improve the service and provide an increased quality of life for residents, focusing on equality and diversity issues. Monthly meetings are held with residents to discuss issues. Opportunities are available for those residents who wish to be more involved to be members on various committees representing their interests. The home has quality assurance systems in place. On the day of the inspection a person from the organisation’s quality assurance team conducted an audit on the home’s medication process. The manager said that the home had targeted the views of residents, family, friends, advocates and stakeholders on how it was delivering its service. She was now in the process of carrying out a further self-assessment on the care provision. Information submitted in the pre-inspection questionnaire indicated that the home has good systems in place for the regular maintenance of equipment such as fire, central heating, bath hoists and passenger lifts. The fire panel is checked weekly and regular fire drills are carried out monthly. It was noted that the list of staff names attending the fire drills were not recorded. The manager was advised to record the names of staff who participated in fire drills in order to comply with best practice guidelines. It was noted that data sheets relating to COSHH (Control of Substances Hazardous to Health) solutions were updated annually. Staff are expected to undertake updated training in health and safety. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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 YA34 Regulation 19(1)(b) Schedule 2 Requirement To comply with the current recruitment guidelines a criminal record bureau (CRB) clearance must be obtained when staff progress into a different care position. Evidence must be available to confirm that PoVA first checks have been obtained for individuals before commencing employment. Timescale for action 15/06/07 2 YA34 19(1)(b) Schedule 2 15/06/07 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 YA20 Good Practice Recommendations The home should ensure that there is a risk assessment in place for all people who self-medicate and that it is kept under review to ensure that any identified risks are eliminated or minimised. Medicines to be administered to people who use the service should have a printed label with the individual’s name, strength of medicine, dose and frequency to comply with the Royal Pharmaceutical best practice guidelines. DS0000022961.V331840.R01.S.doc Version 5.2 Page 26 2 YA20 Chiltern Cheshire Home 3 4 YA34 YA34 The status of staff visas should be current and available to ensure that individuals are fit to work and care for people who use the service. A recent photograph should be held on staff members’ files to confirm proof of identification. Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chiltern Cheshire Home DS0000022961.V331840.R01.S.doc Version 5.2 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!