Inspection on 01/10/07 for Chiltern Retirement Home

This inspection was carried out on 1st October 2007.

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

Chiltern Retirement Home 23/05/06

Chiltern Retirement Home 27/10/05

Chiltern Retirement Home 14/06/05

Chiltern Retirement Home 25/02/05

Chiltern Retirement Home 09/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Chiltern Retirement Home 23 Kingsfield Oval Basford Stoke-on-Trent Staffordshire ST4 6HN Lead Inspector Peter Dawson Key Unannounced Inspection 1st October 2007 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chiltern Retirement Home DS0000008210.V349640.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 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. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chiltern Retirement Home Address 23 Kingsfield Oval Basford Stoke-on-Trent Staffordshire ST4 6HN 01782 711186 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) Chiltern Residential Homes Limited Miss Kerry Jane Colley Care Home 14 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (14), of places Physical disability over 65 years of age (4) Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1) The registered person may provide personal care and accommodation without nursing for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any category 14 [OP 14]. Dementia over 65 years of age 4 [DE(E) 4]. Physical Disability over 65 years of age 4 [PD(E) 4] 2) The maximum number of service users to be accommodated is 14. 2. Date of last inspection 23rd May 2006 Brief Description of the Service: Chiltern House is situated in a pleasant residential area close to Newcastle and is easily accessible by public transport. The home has category to admit up to 14 people over the age of 65 years, some of whom may have dementia care needs or physical disabilities. There are 10 single and 2 shared bedrooms, seven have en-suite facilities. There is an assisted bathroom and separate shower room with walk in shower, both located on the ground floor. There are bedrooms on the ground and first floor, with access to the first floor via the stairs or stair lift. The environment is well maintained and standards are good. The home changed ownership in February 2007 and a new Registered Manager appointed in July 2007. The transition was smooth and successful. Some refurbishment of the home is planned by the new owners. Some positive changes have already been made. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector over one day from 8.45 am – 2.30pm. The home was inspected against the National Minimum Standards for Older people. An Annual Quality Assurance Assessment had been completed by the home and returned to CSCI within the required timescale but not available at the point of inspection and not seen prior to completion of this report. There was an inspection of the physical environment. Documentation relating to the inspection process including care plans, risk assessments, staff files, medication records etc were seen, the only documents not available were residents contracts with the home and a sample is to be faxed to CSCI. All residents were seen and the majority spoken with. All had very positive comments to make about the care they received and the staff delivering the service. Recent changes of ownership and management had clearly not presented any problems for residents. Visiting relatives were not seen on this visit but a visiting GP and District Nurse, who visited separately, were both spoken with and said that dialogue and cooperation with staff at Chiltern House was good. Both said that staff had a good awareness of health care issues and made early referrals if there were any concerns about a resident’s health. Relationships are obviously very relaxed and positive. There were 14 people in residence at the time of this inspection. There were no vacancies. The weekly fees for care at Chiltern House are £376. What the service does well: A small home with established positive and friendly relationships between residents and staff. There is a relaxed, homely atmosphere and good engagement observed with residents. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 6 Visitors are welcomed at any time, some seen visiting around 9 .am. in the past and all confirmed there is an open visiting policy and that they are kept informed about the progress of their relatives. Staff have good awareness of health care needs with early referrals to health professionals if there are any concerns. What has improved since the last inspection? What they could do better: Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 7 Social histories should be provided for all residents. This will provide a more informed approach to areas of their lives not least the provision of social and recreational facilities and individual dialogue/engagement. Referrals to the Nursing Service should be made where there are indications of a history of pressure damage and where Waterlow risks are high. All prescribed medication including creams and nebulisers must be recorded on MAR sheets and signed when given/applied. Further staff training is required in the areas of Dementia Care and the Protection of Residents. Review night checks of residents to ensure they are not disturbed at the hourly Intervals. Records all complaints, including minor ones. Provide recent photographs of all staff. 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 Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Updated and improved statement of purpose/service users guide. Pre-admission procedures are followed and good. out in the persons current environment. Assessments always carried Contracts are provided for all. Confirmation of private contract required to be faxed to CSCI. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose/Service Users Guide have been updated to reflect the change of ownership of the home and the new Registered Manager. This is presented in an improved and easy to read format. All residents have been given a copy and copies available for prospective residents/families. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 10 Funded residents have contracts with the Local Authority, self-funding residents have contracts directly with the home. Copies of contracts were not available in the home during the inspection and the provider will fax a copy to CSCI of a contract for the self-funding resident identified. Pre admission assessments are carried out prior to admission by the homes staff. In relation to a resident admitted from hospital there was an assessment completed prior to discharge from hospital by the Manager and Deputy. A Care Management Assessment had also been obtained prior to admission and both provided the basis of the care plan established. Prospective residents are invited to view the home prior to admission, although this is not always possible (in hospital etc) relatives always visit, view the home and have discussions with staff. A recently admitted resident was spoken with and confirmed that she had made the decision about the suitability of the home with her relative. She also said that she had been helped to settle well into the home by supportive staff. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Health & personal care needs are clearly stated and monitored. Social histories are not and this should be improved . The medication system is satisfactory but it is important that all medication is prescribed and included on the MAR sheets. Residents said that their privacy and dignity were promoted by staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several care plans were sampled for new and long-term residents. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 12 All were based upon assessments of need. Documentation was to a good standard with the clearly defined needs and actions required to meet them. There is a 24 hour plan of care for each person on easy-read A4 page, outlining the hourly needs of residents. Risk assessments were in place for moving & handling, fire safety and risks of daily living. One was established for a resident known to have stored medication. Care plans and risk assessments are all reviewed on a regular monthly basis. In the records of a recently admitted resident was the homes pre-admission assessment, care management assessment and completed risk assessments relating to Moving & Handling and other risks of daily living. A discharge letter from a hospital stated a recently healed pressure sore had been present and there was a high waterlow risk assessment. The person was pressure sore free and had a pressure relieving cushion but not a mattress overlay. This was discussed with the visiting District Nurse who felt that one should be provided as a preventive measure and would arrange provision. Health care information is good. Staff have awareness of the need for early referral to health care professionals. A GP from the local surgery where most residents are registered visited during the inspection upon the request of the home following concerns about a residents unidentified pain. The GP said that the home were helpful and cooperative in health care matters. This was separately reiterated in a conversation with the visiting District Nurse about a totally dependent resident who has been bedfast for the past 3 years and continues to received a high standard of care to maintain good tissue viability and general care. A resident sleeping continuously during the inspection was discussed. She has recently had a medication change and she is being monitored closely for sideeffects and will be referred back to Consultant Psychiatrist if the drowsiness continues. All residents are checked hourly throughout the night. Some bedroom doors required attention, including door closers to operate silently. One person had complained that she was awakened as the checks were carried out. It is recommended that this is reviewed with the staff group to establish a protocol for checks with minimal noise/intrusion. The Manager will do this. A requirement was made in the last report to provide social histories for all residents and used as a working tool to assesses social and recreational needs. Little has been done in this area and this will now be addressed by the home. Methods of obtaining this information were discussed Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 13 The medication system is provided by the local Co-op Pharmacy who inspect the system periodically. A good service is reported from the Pharmacy. Medication records showed satisfactory recording of the receipt, storage, administration and disposal of medication. Two shortfalls were however noted: A nebuliser was not entered on the current MAR sheet and this will be brought to the attention of the Pharmacy. Aqueous cream seen in a bedroom had a label with no name and also was not recorded on the MAR sheet. This cream was supplied by relatives and had reached its expiry date. This should be prescribed and recorded on the MAR sheet as administered. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Shortfalls in the provision of social and recreational activities have been addressed. Their social, religious and recreational needs are being met. Family contacts are part of the care philosophy of the home. Food provision, though not a previous area of concern, has improved and options increased with the appointment of catering staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the last inspection residents indicated in written feedback and in discussions, that there were minimal activities/occupation provided for them. Actions to provide greater occupation and leisure time activities were needed and a requirement to consult and provide more occupational activity in the home was made. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 15 This has been addressed with the appointment of an Activities Coordinator to lead on activities in the home. This person has the interest and skills to extend this provision and although only recently introduced have been successful and stimulating for residents. A course is presently being sourced to provide the Coordinator with suitable training that she seeks. Additionally the home continues to provide monthly musical entertainment and also music to movement sessions from external providers. On the day of this unannounced inspection local Church of England clergy provided an in-house service which residents clearly enjoyed. Roman Catholic clergy provide a regular service to other residents on a regular basis. Visitors are welcomed at all times in this small home and generally many seen during inspections who have spoken positively about the way they are received and kept informed of their relatives progress. Some residents go out with relatives. One persons goes out regularly alone shopping in the local town enjoying a very flexible lifestyle. Since the change of ownership of the home some 6 months ago catering staff have been appointed working 30 hours per week. Previously care staff provided the catering service. The new provision has improved the choice of food and also released care staff additional time for caring, not catering duties. This is a vast improvement. Two residents commented upon the availability now of cooked breakfast options. Catering staff now consult residents about menu compilation and daily about food choices and options. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There is a clear and concise complaints procedure. It is important that all complaints are documented. Some training is required in relation to the Protection of Vulnerable Adults and being arranged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure in place and available for all in the reception area of the home. This is included in the Statement of Purpose/Service Users Guide (revised) and copies given to all residents. No complaints have been received by CSCI concerning this home over the past 5 years. The home has received 2 minor complaints since the last inspection that have been dealt with adequately and satisfactorily but they have not been recorded. It is important that all complaints are recorded with outcomes. The home are aware of the need to ensure the legal rights of residents. This was borne out in discussion and documentation seen in relation to a decision for DNR (Do no resuscitate) document which had been correctly prepared, agreed with doctors and in correct legal form. The home are advised to access Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 17 some training on the Mental Capacity Act 2005 which came into force this year. This will update knowledge in this changing area. Further staff training is required in training relating to the protection of vulnerable adults (Safeguarding). The Deputy Manager is to access a course to enable her to become an approved trainer in this area of work. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The environment is safe and well-maintained. Improvements made to the fire detection system. There are good facilities adequate for the resident group and meet specialist needs. Bedrooms are well presented and some upgrading is planned also. Standards of hygiene are high and well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 19 The home is suitable for its stated purpose. It is well maintained. All areas are bright and adequately furnished and there is a very high standard of cleanliness throughout the home. There are 21 domestic hours with good cleaning routines in place. The new owners intend to replace the majority of the carpets throughout the building. Carpet has been purchased and is on-site, estimates for redecoration of many areas obtained. Some bedroom furniture, mainly in the older part of the building is planned for replacement. There are 2 shared bedrooms (1 on each floor) both are of adequate size and have portable screens to ensure privacy. Residents sharing have consented and agree the sharing. Bedrooms are bright, soft furnishings, bedding and equipment is to a high standard – all present well and are personalised reflecting individuality There is an assisted bath and also a walk-in shower room on the ground floor offering choice of bathing options. Seven bedrooms have en-suite facilities. Access to the first floor is by stair-lift and there are grab-rails, raised toilet seats and frames in relevant areas. There is a single lounge area which divides naturally into 2 areas. There is a separate dining area including a recessed area, often used to entertain visitors or residents to use for privacy. The fire detection system has been upgraded on direction of the Fire Officer. This has included additional detection in the small laundry area which is located off the main lounge area and is obviously a high fire risk area. It is important to ensure the access door to the laundry is closed at all times. Infection control is good. Soap and towel dispensers have been installed in all bathroom and toilet areas recently improving upon the traditional soap/towel use. The home is always clean and fresh, mal-odours never present. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Staffing numbers have increased with the appointment of catering staff, releasing carers from this task. The minimum number of 50 of trained NVQ staff by 2005 has not been met. This target should soon be met. Shortfalls in dementia care training and Safeguarding are being addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels have improved since the last inspection and the change of ownership. There are 2 carers on duty throughout the day plus the Manager or Deputy during the day. This applies over 7 days. At night there is one carer and a person sleeping in and on-call for 5 nights and there are 2 carers on duty on the other 2 nights. The home would review this situation if a resident required a higher level of care during the night for example increased dependency/health needs, terminal illness etc. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 21 A new post of Senior Carer has been established with the objective of having a Senior member of care staff on duty wherever possible. The significant change is the appointment of catering staff – Previously care staff also prepared meals – this means that an improved catering service is provided releasing care staff for pure care duties. The new system is working well. Additionally an Activities Coordinator has been appointed to lead activities in the home. There were shortfalls in this area previously and improvements have been made in the number and type of activities provided. This has ensure compliance with a previous requirement. There are 14 care staff - 2 staff have NVQ2 training or above. 5 are presently studying NVQ and 3 still to enrol for courses. The target of 50 of NVQ trained staff is not met at this time but hopefully this will be met as the training continues. Statutory training has been provided for staff in most areas. There are two shortfalls – only 2 staff have had training in dementia care and the Protection of Vulnerable Adults (Safeguarding). The Deputy Manager is to attend Safeguarding training to become an approved trainer for other staff. The Manager is currently an approved Moving & Handling trainer and it is proposed that another member of staff takes on this role. Moving and handling training in the home is arranged for 2 sessions during October. There is a good induction training programme for new staff providing training over the first 6 weeks to Skills for Care standards. A sample of staff files were inspected and contained all appropriate references, checks and POVA/CRB checks. The home are aware of the need to supervise new staff who have had POVA clearance but await CRB clearance. All required documents under Schedule 2 were in place in the files seen with the exception of recent photographs for staff members. The Manager will ensure these are obtained. All staff had had new contracts of employment with the new owners of the home. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There has been a smooth transition to new ownership and management of the home. The Registered manager has the necessary experience and obtaining the necessary qualifications to run the home. There is an open but positive management style in place. Staff supervision has improved. The health, safety and welfare of residents are promoted and protected with good recording and monitoring of health and safety factors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 23 The home has changed ownership and management since the last inspection. The previous Registered Manager was also a Director. Ownership changed in February 2007 the former deputy to the Manager became the Acting Manager and was approved by CSCI as the Registered Manager in July 2007. The new owners visit the home on 2 evenings each week and there is ongoing contact in between as necessary. Memos were seen in the home from the new owners. They are reminded under Regulation 26 that the Responsible Individual must visit the home unannounced at least monthly, prepare and leave a copy of the report of the visit in the home for the registered manager and subsequent inspection. The transition of change of ownership has been smooth, residents and staff aware of the changes. Discussions with residents showed no concerns, in fact they had not “noticed any changes” that may affect them. The Manager reports positive dialogue and support with the new owners. The Registered Manager does not have the required qualifications at this time but is presently studying the for the Registered Managers Award agreed with CSCI for completion by 2008. She will then complete the required NVQ4. Staff supervision has improved since the last inspection and the aim is to provide supervisions for all staff 6 times per year. There are no residents meetings, although dialogue with residents is established easily and ongoing in this small home. The Manager speaks to residents individually prior to the staff meeting and any concerns are discussed and addressed. Some deficiencies in fire safety were identified in the Fire Officers letter dated 15/5/07 and all appear to have been addressed. A new fire control panel has been installed with additional sensors etc. as required. The Fire Risk Assessment has been completed and each resident risk assessed (copies in care plans) in relation to actions required in the event of fire. Evacuation procedures and arrangements have been revised/established. The Fire Officer is due to revisit and approve the changes made. All deaths in the home are now reported to CSCI as required in the last report. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 24 Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement Social histories must be completed for all residents and used as a tool to asses social needs. Previous requirement not met. Timescale for action 31/10/07 2. OP8 12(1) 3. 4 OP9 OP30 13(2) 18(1) Ensure referral for preventive 08/10/07 equipment where this is a history of pressure damage and/or high risk. Ensure all creams are prescribed 08/10/07 & recorded on MAR sheets and nebulisers recorded also. Staff training required in areas of 31/12/07 Dementia Care & Safeguarding (Protection). 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 OP19 Good Practice Recommendations Ensure silent operation of doors & door closers and review with staff actions taken when hourly night checks are DS0000008210.V349640.R01.S.doc Version 5.2 Page 27 Chiltern Retirement Home 2. 3. OP16 OP29 made. All complaints, including minor ones should be recorded with outcomes. Provide recent photographs of staff on staff files to comply with Schedule 2. Chiltern Retirement Home DS0000008210.V349640.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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