Inspection on 17/08/06 for Chilterns End

This inspection was carried out on 17th August 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chilterns End 11/06/08

Chilterns End 08/06/07

Chilterns End 30/01/07

Chilterns End 05/01/06

Chilterns End 21/07/05

Chilterns End 17/02/05

Chilterns End 30/09/04

Chilterns End 03/02/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Chilterns End Greys Road Henley On Thames Oxfordshire RG9 1QR Lead Inspector Jane Handscombe Unannounced Inspection 17th August 2006 11:00 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 Chilterns End DS0000013154.V308194.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. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chilterns End Address Greys Road Henley On Thames Oxfordshire RG9 1QR 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) 01491 574066 01491 574633 manager.chilternsend@osjctoxon.co.uk The Orders Of St John Care Trust Mrs Pauline Anne Krason Care Home 46 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (21), Learning disability over 65 years of age (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (1), Old age, not falling within any other category (46), Physical disability over 65 years of age (13) Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 46. 5th January 2006 Date of last inspection Brief Description of the Service: Chilterns End is a purpose built care home that was purchased by The Orders of St John Care Trust from Oxfordshire Social Services in the latter part of 2001. The home provides accommodation and care for a maximum of 46 older people over the age of 65, some of whom may be mentally or physically frail. The home also provides day care and respite short stays for a small number of people. The accommodation is provided in single rooms in a one-storey building. Chilterns End is set in its own grounds on the outskirts of Henley-on-Thames and is close to local health centres, shops and Townlands, the community hospital. The home has four units, each with its own kitchenette, dining and sitting rooms and there is also a large main dining room. Each unit has assisted toilets, bath and shower facilities. The building surrounds a central garden with a sensory area, planted with herbs and aromatic plants and a water feature. The garden and grounds have a range of garden seating and shaded areas, with easy access for residents from most areas of the home. The fees for this service range from £484.00 to £695.00 per week. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’ involving one inspector, which took place over one day. The inspector arrived at the service on 17th August 2006 and was in the service for 8.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Comments received from residents included: ‘My daughter comes forthnightly, they always make her a cup of tea’. ‘Staff are excellent’. ‘The staff are really very good here’. ‘I have no complaints’. ‘I would say everything’s good here, I don’t have to stay here and I don’t wish to change’. ‘My daughter tells me I’m getting value for money’. ‘The food is very good, plenty of it’. ‘A credit to all the staff in making our home so nice, including the gardens’. Comments from staff included: ‘Its turned around since this manager has been in post…….best one I’ve ever worked for, she’s brilliant…..I can go to her about anything’. ‘I find the manager very approachable, would deal with any concerns appropriately’. The inspector would like to thank residents, relatives, staff and all those who kindly gave their time to help during this inspection. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas in which the home could improve upon, to ensure the health, welfare and safety of those using the service. The recording and administration procedures for medication were of a very poor standard, clearly placing the residents’ welfare into question. Procedures around the administration and recording of medication must be adhered to at all times, keeping full records of what has been given, when and by whom. The reviewing of care plans and the monitoring of residents’ weight needs to be undertaken on a regular basis to ensure any changes in the residents’ needs are recognised and addressed appropriately. All service users’ care plans must contain a recent photograph. Whilst undertaking an assessment of needs, the assessor must ensure they are thorough and recognise every aspect of the resident’s needs in order that staff are aware of these and how to address them. Failing to recognise important Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 7 mental health needs, as was the case in one care plan viewed, clearly evidences that this particular assessment was not thoroughly undertaken. Service users would benefit from staff spending more one to one time with the residents they provide the care for, which was clearly failing on the day of inspection. This was an area which residents spoke to the inspector about and felt the need for. Whilst staff undergo a programme of training, the manager must ensure that all mandatory training is updated when it becomes due. As was recommended during the last inspection, the manager must ensure to implement a programme of formal supervision so that all staff have the recommended number and frequency of sessions. It is recommended that the manager address the concerns around poor communication with relatives and reminds relatives that they are encouraged to voice any complaints/concerns. It is recommended that residents are offered a wider variety of choices around recreational interests, which offer both mental and physical stimulation. 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. Chilterns End DS0000013154.V308194.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 Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is generally good. This judgement has been made using available evidence, including a visit to this service. Systems are in place to ensure assessments are undertaken prior to a service user moving into the home. Service users are provided with written contracts/statement of terms and conditions with the home. EVIDENCE: The inspector was informed that either the home manager or a senior member of staff visits all prospective service users to undertake an assessment of needs prior to moving into the home. An assessment of needs is undertaken to ascertain if the home has the capacity to deliver the care required, although of the five viewed, one failed to mention an important aspect of the resident’s mental health. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 10 Discussions with service users evidenced that assessments had been undertaken, with their involvement, prior to their moving into the home. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Contracts viewed by the inspector were found to be appropriate and signed by the relevant parties. Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The care planning system is of poor quality; they do not contain sufficient information to ensure that all needs are met appropriately and are not reviewed as often as is required. The staff ensure that the service users’ dignity, privacy and individuality are maintained at all times. The home’s procedures around the recording of administration and recording of medication are poor. EVIDENCE: The plan of care is drawn up from the initial assessment of needs. This is drawn up with the active involvement of the service user/representative, who agree and sign it where capable of doing so. Five service users’ care plans and assessments were inspected during the inspection, all of which had some shortcomings. The review of care plans was Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 12 not being undertaken on a monthly basis and likewise, the residents’ weights were not being monitored appropriately. Two of the care plans did not contain a photograph of the resident and one failed to mention an important aspect of the resident’s mental health on either the admission details or long term assessment of needs. One service user’s care plan was very minimal containing only details on personal care. It was noted that this resident has a history of falls and details of a recent fall had been noted, although no risk assessments had been undertaken and put into place. Of the care plans viewed, there was no evidence that residents nutritional status had been assessed on admission and regularly reviewed, using a recognised assessment tool: the Malnutrition Universal Screening Tool (MUST) is recommended. Feedback received from GPs and Health and Social Care professionals who are in contact with the home was generally positive, however there was one which suggested that ‘it would be good for staff to attend a formal continence session so that care is more consistent and problems highlighted’. The registered manager must ensure that residents’ assessment of needs and their care plans contain sufficient information in order that all needs are met appropriately. Regular reviewing of these needs must be undertaken on a monthly basis or sooner if the need arises. Whilst the home has policies and procedures to ensure the health, safety and welfare of the service users, poor procedures were observed around the storing and recording of administration of medication, which were of a very poor standard. The inspector accompanied a senior carer on the medication round, during which the carer who did not actually administer the medication and was not present at the time signed for medication administered earlier in the day. During the round, it was noted that medication administered the previous evening, in one unit of the home, was not signed for on a service user’s Medication Administration Record (MAR). Upon enquiring further, it was found that none of the residents’ MAR sheets had been signed, in that unit, to signify that their medications had been administered. The inspector viewed the controlled drugs register and found that the number of controlled drugs held in the medication cabinet, did not match up to the totals written in the register. These findings clearly put the residents’ health and welfare into question, since it was not possible to ascertain whether residents had received their medications as required and therefore their needs met. Whilst touring the premises, medication was found in one communal bathroom, which the inspector removed and handed in to a senior carer to store safely and appropriately. Upon discussion with the manager, it was ascertained that these issues would be addressed and appropriate action would be taken. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 13 Staff were observed to treat the service users with dignity and respect, speaking to them by their preferred name and knocking on doors before entering their rooms. Service users informed the inspector that this was always the case. Service users and their families are assured that at the time of death, they will be treated with dignity and respect, and their spiritual needs and associated rites will be observed. Every effort is made to ensure the best possible care is provided at this time and support to the families and friends through what is a very difficult time. Information about the residents’ wishes at their time of death is obtained wherever possible at the time of their admission to the home, and this was observed on examination of the care plans. Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Visitors and friends are welcome to visit the residents at any reasonable time. A daily programme of activities is provided for service users to take part in, although they do not offer much variety or physical stimulation. Service users are helped and assisted to maintain choice and control over their lives. Residents receive a wholesome nutritious diet, and every effort is made to ensure that meal times are a pleasurable experience. EVIDENCE: Whilst the home offers a weekly programme of activities to those who use the service, these were found to offer one activity per day and to be very basic, offering very little variety or physical stimulation. It is recommended that the daily programme of activities offers a wider variety of choices around recreational interests, which offer both mental and physical stimulation. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 15 Friends and volunteers visit the home and provide sing-along which service users enjoy. A recent trip offered to the residents was a visit to Whipsnade Zoo, which was enjoyed by those who took part. Sunday services and communion are provided for those who wish to attend. Residents are encouraged, and assisted where the need arises, to maintain links with their family, friends and representatives of their local community. One resident informed the inspector that her daughter visits fortnightly and explained that on each visit the home makes her welcome ‘they always make her a cup of tea’. Residents are able to access a hairdressing service offered by a visiting hairdresser who attends the home each week. It was mentioned by a couple of residents that recently they had been without a hairdresser but that ‘X’ (named carer) comes in on her weekend off’. During the inspection, the inspector spoke to residents about the choice of meals offered. Generally, they were happy with the meals offered, although a number were disappointed that lamb chops had been removed from the menu. The manager informed the inspector that meals were a subject discussed at the residents meetings and that it is an area in which a lot of work is presently being undertaken, that its being looked into throughout all The Orders of St John care homes and the chefs are in discussion with the catering manager employed at The Orders of St John county office. Chilterns End DS0000013154.V308194.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Arrangements are in place to ensure that service users, relatives and friends may voice any concerns which will be dealt with appropriately. Staff are fully conversant with procedures in relation to any allegations or suspicions of abuse. EVIDENCE: Residents are provided with details of the complaints procedure in their Service User Guides, and details are posted on the notice boards within the home. Residents spoken to on the day of inspection were aware of the complaints procedure and felt that if they had any concerns they would be taken seriously and acted upon appropriately. Regular residents meetings are held, which keep residents informed and allow for any concerns to be discussed. The meetings are minuted and distributed around the home. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff member’s responsibility to ‘whistle blow’ on any poor practice or concerns that come to their attention. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 17 The home has received two complaints during the last twelve months, one of which was partially substantiated and both of which were responded to within 28 days as per the home’s complaints procedure. The Commission for Social Care Inspection has not received any correspondence from the general public in relation to concerns, complaints or allegations since the last inspection undertaken in January 2006. However, prior to the inspection, six comment cards were received from GPs and health and social care professionals who have contact with the home. Of these six, five have not received any complaints about the home, although one states that they have received verbal complaints from relatives; ‘feedback highlights the need for better communication so relatives can feel better informed and reassured re care given’. A further comment was that they were not satisfied with the overall care provided to service users within the home, that ‘care does not seem to be at a consistently high/thorough standard’. It is recommended that the manager address these concerns and reminds relatives that they are encouraged to voice any complaints/concerns. The home facilitates access to advocacy services and takes steps to ensure that residents are enabled to take part in the local and national elections if they require. Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home presents as clean, hygienic and free from any offensive odours throughout. Residents are enabled to access all their communal and private space, through the provision of specialist equipment which include ramps and a passenger lift. EVIDENCE: Residents are enabled to access all their communal and private space, through the provision of specialist equipment which include ramps and a passenger lift. The home provides sufficient WC and washing facilities and provides grab rails in corridors; assisted toilets and baths are available to ensure all residents’ needs are met. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 19 There is adequate provision of toilets, washing and bathing facilities throughout the home. All rooms have call systems with an accessible alarm facility, which allows residents to call staff in the case of an emergency. Residents spoken to informed the inspector that in situations where they have had to use this alarm they had been answered swiftly and appropriately. Bedrooms viewed on the day were individually styled with residents’ personal possessions and were pleasantly decorated and homely. One resident in discussion with the inspector said ‘I love my room, I have a lovely room and its always very clean’. Whilst touring the home, it was observed that a number of wheelchairs were being stored in a hallway. The home must store wheelchairs appropriately to allow easy access to all parts of the home. The fire service and environmental health departments within Oxfordshire carry out inspections to check that areas of safety falling within their remit are satisfactory. The home manager ensures to comply with the standards set by these agencies. Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Recruitment procedures are robust and staff appropriately vetted, to ensure that service users are protected. Staff receive training to ensure that they are equipped with the skills to provide a good standard of care in a safe, competent manner, although the updating of the mandatory skills needs to be taken in a timely manner. Whilst the staffing levels meet the requirement they do not appear to allow for quality time to be spent with residents. EVIDENCE: The inspector was informed that the home’s comprehensive recruitment procedures ensure as far as is possible that residents are in safe hands. The inspector viewed 4 staff members’ files that were chosen randomly. Whilst discrepancies were found in the recruitment procedure of three, it was acknowledged that recruitment was undertaken by the previous manager and was no fault of the present manager. A recently appointed member of staffs’ file was viewed and evidenced that a comprehensive recruitment procedure had been followed and all relevant pre-employment checks had been undertaken. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 21 Whilst viewing staff files, it was noted that a number of staffs’ mandatory training was out of date, however information received from the manager highlights that all mandatory refresher training is planned for. There were two instances in which there were no recent photographs held on the staff members’ personnel files, however the inspector was informed they would be rectified. All new staff undergo an induction training in order to give them the skills necessary for caring for the residents’ needs. This is followed by further training in any areas relating to the needs of the residents who are in their care. During the last twelve months, staff training has included first aid, fire training, basic food hygiene, adult abuse, manual handling, infection control, the safe handling of medication, dementia awareness and health and safety. Whilst speaking with residents and general observation throughout the inspection care staff were meeting the residents’ care needs, although there was little evidence of staff offering quality time on a one to one basis. One resident informed the inspector ‘staff don’t have time to sit down and talk to residents’. Whilst speaking with a care staff member it was mentioned that they felt they were just able to carry out the care needs of the residents but would like to be able to offer more quality time to individuals. It is reccommended that the staffing levels and deployment of staff be looked at in relation to the dependency needs of the residents. Chilterns End DS0000013154.V308194.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. In view of the findings during the inspection around assessments, care planning and medication issues, the home is not presently protecting the health safety and welfare of the residents appropriately. The absence of thorough assessments of needs and reviews of these needs does not protect and promote the health, safety and welfare of those using the service and could result in residents being placed at risk. There are clear robust systems in place to protect the residents’ financial interests. A programme of formal supervision needs to be put in place, so that all staff have the recommended number and frequency of sessions. Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 23 EVIDENCE: Whilst the home has policies and procedures to ensure the health, safety and welfare of the service users, procedures are not always being adhered to. Evidence found with regards to the care planning & reviewing, assessment and medication processes (see section headed Health and Personal Care) need to be addressed in order to remove the risk factors to the residents’ health, safety and welfare which are clearly evident at present. The inspector met with the administrator and discussed the management of the residents’ finances. The systems and records were examined and found to be in good order and provided a clear audit trail to safeguard the residents’ financial interest. The inspector was informed that staff receive regular supervision both formally and informally. However, whilst in discussion with two care staff, the inspector asked when they last had a supervision, one said ‘ year or more, I cant remember’ whilst the other said ‘I had one in ten years’. As was recommended during the last inspection, the manager must ensure to implement a programme of formal supervision so that all staff have the recommended number and frequency of sessions. Chilterns End DS0000013154.V308194.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 X 3 3 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15,17 Schedule 3 Requirement * The registered manager must ensure that care plans are reviewed and monitoring of weight at least every month and re written if residents’ care needs change significantly. * Residents’ assessment of needs and their care plans must contain sufficient information in order that all needs are met appropriately. * A photograph of each resident must be held on file. The registered manager must ensure that staff adhere to the procedures for the safe storage, recording and administration of medicines. The registered manager must ensure that all mandatory training is updated when it becomes due. All staff personnel files must contain a recent photograph. Timescale for action 31/10/06 2 OP9 13(2) 30/09/06 3 OP30 18 31/10/06 4 OP29 19 Schedule 2 30/09/06 Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 26 5 OP36 18 The manager must ensure to implement a programme of formal supervision so that all staff have the recommended number and frequency of sessions. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP38 Good Practice Recommendations It is recommended that residents are offered a wider variety of choices around recreational interests, which offer both mental and physical stimulation. It is recommended that the home ensures that wheelchairs are stored appropriately to allow easy access to all parts of the home without obtrusion, thereby ensuring the health, safety and welfare of the residents, visitors and staff. It is reccommended that the staffing levels and deployment of staff be looked at in relation to the dependency needs of the residents. It is reccommended that the manager address the concerns around poor communication with relatives and reminds relatives that they are encouraged to voice any concerns/complaints. 3 4 OP27 OP16 Chilterns End DS0000013154.V308194.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU 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 Chilterns End DS0000013154.V308194.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. 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