Inspection on 09/02/06 for Chilton Court Residential Home

This inspection was carried out on 9th February 2006.

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

Chilton Court Residential Home 07/08/07

Chilton Court Residential Home 05/09/06

Chilton Court Residential Home 16/05/05

Chilton Court Residential Home 25/02/05

Chilton Court Residential Home 17/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Chilton Court Residential Home Gainsborough Road Stowmarket Suffolk IP14 1LL Lead Inspector Tina Burns Unannounced Inspection 9th February 2006 11:30 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 Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 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. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chilton Court Residential Home Address Gainsborough Road Stowmarket Suffolk IP14 1LL 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) 01449 675320 01449 675320 simon@stowcare.co.uk Stowcare Limited Mrs Jean Mary Hayward Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Chilton Court is a registered care home for up to 47 older people. It was first registered in 1986 to accommodate 19 service users. In April 1998 the home increased its registration to 23 service users and then to 33 service users in January 2000 following the building of an extension. In September 2000 the owners extended the service by opening ‘The Courtyard’, a care housing complex on the same site as Chilton Court. The Courtyard enables people to receive support and assistance with personal care in the comfort of their own homes. It can accommodate up to 14 older people, bringing the homes total registration to 47. The home is situated on the Gainsborough Estate, approximately one mile from Stowmarket town centre. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection that took place on a weekday between the hours of 11.30am and 5.30pm. The registered manager was not on duty at the time of inspection, however the deputy manager and general manager, Mr Simon Gibb, were on site throughout the inspection and fully contributed to the inspection process. The inspection included a tour of the premises and examination of a wide range of documentation including staff records, service user care plans, staff training records and a variety of policies and procedures. The inspector also spoke with two care staff and seven service users. What the service does well: What has improved since the last inspection? What they could do better: The home must develop residents care plans so that they include the action required to meet individual needs. They must also be completed in consultation with residents and reflect their personal wishes and requirements with regard to personal care. There must also be evidence that residents have access to their care plans. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 6 Minor amendments need to be made to the homes Statement of Purpose and Complaints procedure to ensure that it complies with legislation. The home must also ensure that all residents have an up to date copy of the complaints procedure. The home must also ensure that residents are helped to exercise choice and control over their lives and consulted about the quality of care within the home. Appropriate training should be undertaken by all staff employed at the home and include dementia care and Protection of Vulnerable adults. The registered manager must undertake a review of staffing levels to ensure residents needs are met at all times, the general manager must have a job description in place and records must evidence that staff are appropriately supervised. 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. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 7 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 Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 8 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): 1, 2, 3, 4 & 5. Prospective residents are able to make an informed choice about living at the home but, with the absence of detailed pre admission assessments, they cannot be certain that their needs will be met. EVIDENCE: The home had a Statement of Purpose and Service User Guide in place. The Statement of Purpose had been amended since the previous inspection to reflect the fact that the previous Registered Manager had left, however it had not been updated to reflect the fact that the new manager is registered and is no longer the ‘acting manager’. The Service User Guide included information about the homes facilities, aims and objectives, complaints procedure and terms and conditions of residence. Two residents records were examined. The records included a needs assessment and admission form completed by the home prior to each resident’s admission. Although the template used covered a wide range of needs the forms had not been completed in detail and did not provide enough information to develop a care plan based on the individuals needs, wishes and aspirations. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 9 The home has a small number of residents with mild dementia and although this is not currently reflected on the homes certificate of registration the home is working to resolve this with the Commission of Social Care inspection. However, the Statement of Purpose specifies that the home cares for people with mild dementia but it is not registered to provide dementia care and must not accept any new residents that have dementia. This is not made clear in the Statement of Purpose. The Statement of Purpose also states that the home provides care to people over 65 with a range of physical disabilities and conditions including partial sight, Parkinson’s disease and strokes. However training records indicated that the home does not provide any specialist training in these areas or in the area of dementia care. Contracts were in place in the two residents records examined and indicated that all residents are initially accommodated on a trial basis of a minimum of one month. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 10 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 & 11. Residents are not appropriately consulted about their individual care plans and although their health needs are likely to be met they cannot be certain that the home will respect their wishes or meet their broader needs. EVIDENCE: Two resident’s care plans were examined during the inspection. Each care plan had been devised using the same ‘electronic’ template. The template covered a wide range of social, emotional and physical needs. The plans identified the individual’s needs but they did not clearly specify the tasks that must be undertaken to meet the needs. Furthermore, there was no evidence that the plans were developed in consultation with the residents and little evidence that residents wishes, aspirations, likes, dislikes or routines had been accounted for within the care plans. It was also evident that although manual handling assessments and environmental risk assessments were carried out there was no evidence of personal risk assessments covering areas such as skin tissue viability and nutrition. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 11 Records relating to the health of two residents were also examined. These were seen to be more thorough and evidenced that the home supports residents to access health care services such as, GP’s, Community Nurses, outpatient’s appointments and Chiropody. Observations regarding the health of each resident were also recorded and appropriate action taken where necessary. The home had appropriate policies and procedures in place regarding the safe handling of medication. Medication was stored and transported appropriately in a lockable metal trolley. The home’s medication was supplied by a large pharmacy using a monitored dosage system; training records indicated that the pharmacy had provided training for staff in the safe handling and administration of medicines. Medication records examined had been signed, dated and completed appropriately. Resident’s medication records did not include photographs of each individual resident. A group of seven resident’s were spoken with during the inspection and observations made at that time were that the residents seemed physically well cared for. Resident’s confirmed that staff were polite and positive comments were made regarding the personal care they receive and the home’s welcoming attitude towards their visitors. Residents spoken with were not aware that they had individual care plans in place and could not confirm that they were consulted about their individual care. Further more, staff spoken with indicated that care workers do not have access to residents care plans. The home had a ‘Dying and Death Policy’ in place that stated, “resident’s will have been consulted…” however records seen did not include the wishes of the residents or their relatives in the event of them becoming seriously ill or dying. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 12 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 & 15. Residents find that their families and friends are made welcome at the home, further more they can expect to enjoy a varied and appetising menu. However residents that are entirely dependant on the homes support may find that their personal choices are limited. EVIDENCE: Residents care plans were not appropriately detailed regarding residents needs and wishes in relation to social and community activities and there was little evidence to suggest that residents are consulted about activities they wish to pursue, within and outside of the home. Although this may not be an issue for the more independent residents some of the residents spoken with said that they felt that the home should provide more opportunities than the activities provided four mornings a week by the homes hobby and craft therapists. Residents agreed that they had to rely on visitors for ‘outings’ and one in particular felt that the home should organise entertainment and planned excursions on a more regular basis. The group of residents spoken with also advised the inspector that the home had a ‘rule’ that the communal television was not allowed on until 6pm and there was mixed feelings amongst the group about whether or not this rule was acceptable. The general manager confirmed the fact that the ‘rule’ was in place and advised that it was to avoid residents falling asleep in front of the television. He also advised the inspector that Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 13 residents wanting to watch television in the daytime could do so with their own televisions in their own rooms. On the day of inspection residents were seen enjoying visits from relatives and friends. Resident’s spoken with confirmed that the home always gave their visitors a warm welcome and that they were able to meet with them in the privacy of their own rooms or in any of the communal areas throughout the home. The home had a large dining room in the main building and further lounge/diner in the courtyard extension. The general manager and deputy manager confirmed that resident’s could take their meals in one of the dining areas or in the privacy of their rooms. Both dining areas were comfortable and well maintained and provided pleasant environments to eat and socialise. Resident’s confirmed that they could make a choice from the homes menu or request an alternative if they wished. Comments indicated that there was a good choice of appetising meals available, one resident said “The food is quite nice” another said “not quite nice, wonderful, very eatable!”. Staff spoken with confirmed that following a recommendation made at the last inspection jugs of fresh water are put on the dining tables at meal times. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 14 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 & 18. Resident’s cannot be sure that their complaints will be listened to, taken seriously and acted upon. Further more the absence of adult protection training for staff does not ensure residents are fully protected from abuse. EVIDENCE: Following the last inspection a requirement was made for the home to amend their complaints procedure in accordance with regulation 22 of The Care Homes Regulations 2001. Further more the home was required to ensure that all residents had a copy of the complaints procedure. The general manager confirmed that the procedure had been amended but he could not recall whether or not it had been distributed to existing residents. The complaints procedure detailed in the homes Statement of Purpose and Service User Guide, given to the inspector during the inspection, still failed to meet requirements by stating that the complainant will receive a “verbal response within one month”. The home did have a complaint ‘log’ in place that indicated there had been no complaints since the last inspection. However, on the day of inspection the inspector witnessed a visitor verbally complaining about a resident wearing clothing not belonging to them. The complainant was not invited to make a formal complaint and the complaint was not recorded. The home had an ‘Abuse Policy’ in place that reflected local authority guidelines in relation to the protocols for reporting and investigating concerns. Staff spoken with were aware of the policy but had not undertaken training in the Protection of Vulnerable adults (POVA). Training records indicated that POVA training was outstanding for the majority of staff employed at the home. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 15 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, 20, 21, 23, 24, 25 & 26. Residents can expect to live in a clean, safe, well-maintained and comfortable environment. Further more they can expect to have rooms that meet their needs and enjoy having their own possessions around them. EVIDENCE: On the day of inspection the home was well maintained, pleasantly furnished and decorated, comfortable and ‘homely’. The main building consisted of a number of communal areas including two adjoining lounges, one independent lounge, a large dining area and enclosed courtyard. The communal areas situated within the Courtyard Complex included a small kitchen, a lounge/diner and a pleasant conservatory overlooking a pond and ‘decked’ area. Accommodation in the main building consisted of 32 bedrooms, one having the capacity to be a double room; all had en-suite toilets and hand basins. There were also sufficient shared toilet and bathroom facilities through out the building. First floor bedrooms could be accessed via a shaft lift. Bedrooms seen were all individually furnished and decorated and provided sufficient and Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 16 comfortable facilities. Resident’s had equipped their rooms with many of their own belongings and personal effects. All bedrooms had a call system in place. The Courtyard extension consisted of self contained one and two bedroom accommodation. The general manager explained that the residents were free to use the communal areas within the main building and Courtyard extension no matter where they were accommodated. On the day of inspection the premises was warm, clean, hygienic and free from unpleasant odours. The home’s laundry area was appropriately equipped and included washing machines reaching maximum temperatures of 95 degrees centigrade. Staff spoken with and training records seen indicated that care workers and ancillary staff had undertaken infection control training. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 17 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 & 30. Residents cannot be certain that there will be adequate staffing levels to meet their needs at all times, further more they are not entirely protected by the homes recruitment procedures. EVIDENCE: The last inspection highlighted concerns made by a number of staff about staffing levels and a requirement was made for the home to complete a review of staffing levels for all shifts. On this occasion there was no evidence that a review had been undertaken and the general manager confirmed that there had been no change in staffing levels. Staff and residents spoken with indicated that they continued to feel the home was inadequately staffed at peak times and constraints on staff time did not enable residents to receive a person centred and needs led service. Discussion with staff and the general manager and examination of the staff rota indicated that staff were ‘stretched’ at times. Evidence included confirmation from the general manger that residents are not assisted with baths at the weekends because care workers have additional laundry duties (the laundry assistant is not on duty at weekends). The recruitment records of two care workers were examined during the inspection. The records evidenced that Enhanced Criminal Record Bureau Checks had been undertaken and were satisfactory for each member of staff. There was also evidence that face-to-face interviews had been carried out and references had been undertaken. Further more records included written Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 18 application forms and health declarations. However, records did not include individual’s photographs or evidence that their identity had been verified. Staff spoken with and training records seen indicated that staff undertake an appropriate induction programme, and receive manual handling, infection control and food hygiene training. Some staff had also undertaken training in first aid, medication, protection of vulnerable adults and continence however, there was no evidence of dementia awareness training for staff working with the residents that have mild dementia. The registered manager is currently undertaking the Registered Managers award and has NVQ level 4 in management of care. Records also indicated that 50 of staff have undertaken or are currently undertaking appropriate NVQ qualifications. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 19 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, 32, 33, 35, 36, & 38. Residents cannot be sure that staff will be appropriately supervised; furthermore their rights and best interests are not protected by the homes procedures for quality assurance. EVIDENCE: Since the previous inspection the homes manager, Jean Hayward, has successfully undertaken the ‘fit person’ process with the Commission of Social Care and is now the homes registered manager. Ms Hayward was not on duty at the time of inspection but the general manager confirmed that she has commenced the Registered Managers Award and has NVQ level 4 in care. The deputy manager, who was on duty at the time of inspection, supports the registered manager in her role. Training records examined indicated that the deputy manager is currently undertaking NVQ level 3. Mrs Hilary and Mr Barry Gibb are the owners of Chilton Court and a second home in Stowmarket and their son, Mr Simon Gibb, is the general manager of Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 20 both homes. Hilary Gibb has nursing qualifications and was previously the homes manager; she now has a supporting role as operational manager and takes a lead in the co-ordination and provision of staff training. Mr Simon Gibb is based at Chilton Court and confirmed that he takes responsibility for the formal supervision of the registered manager. Records seen and conversations with Mr Gibb and staff on duty also confirmed that he takes a lead role in decision making within the home and is actively involved in staff recruitment and supervisions. There was an appropriate job description in place for the registered manager but there was not a job description in place for the general manager. Mr Gibb confirmed that he had not had previous experience working within a care setting or relevant management qualifications. Records seen and discussion with the general manager confirmed that the most recent quality assurance survey was undertaken in 2004 and the subsequent report was completed in February 2005. Mr Gibb stated that the process was “too costly” to do every year and the home had no plans to undertake a further survey at this time. This conflicts with the homes Service User Guide that states “residents and their relatives are asked to complete questionnaires about the home at least once a year”. There was also no evidence of individual service reviews or residents / relatives meetings. The home had an ‘operational procedures’ file in place and several policies were examined during the inspection and seen to have been reviewed in November 2005. This ‘file’ also included ‘Stowcare work instructions’ for personal care tasks. Staff guidelines for bathing and ‘grooming’ indicated that the home needs to develop its practices in some areas as some procedures did not reflect a needs led, personal and flexible service, for example residents were bathed ‘according to the rota’. The general manager confirmed that the home does not handle resident’s monies. Resident’s receive monthly bills which includes their accommodation charges and any other expenses, i.e. newspapers, toiletries, etc. Staff spoken with during the inspection confirmed that planned individual supervision takes place, normally with the registered or deputy manager and the general manager. However there was limited evidence of recorded supervisions and the one record seen had not recorded an agenda or detail of areas discussed. A tour of the premises, records seen and staff spoken with evidenced that the home carries out regular health and safety checks, appropriately maintains the building and provides appropriate staff training including, fire safety, food hygiene, manual handling and infection control. However, the general manager was unable to provide any evidence that a risk assessment had been undertaken to ensure the safety of residents who ‘wander’, this was a requirement made at the last inspection. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 21 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 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X 3 3 3 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 2 2 2 X 3 2 X 2 Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes, there are 7 repeat requirements. 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 1 Regulation 4 Requirement The Registered Manager must ensure that the Statement of Purpose is amended to reflect that the fact that the homes manager is now registered and the home is not able to accept referrals for people with dementia. The Registered Manager must evidence that residents are consulted about and have access to their care plans. This is a repeat requirement. Individual care plans must be more detailed and include how resident’s social, emotional and physical needs are to be met. This is a repeat requirement. The Registered Manager must ensure that all residents are able to make choices and remain autonomous. Where this is not possible appropriate risk assessments and records must be in place. This is a repeat requirement. The Registered Manager must ensure that the complaints procedure complies with DS0000024357.V283106.R01.S.doc Timescale for action 30/03/06 2 7 & 14 15 30/05/06 3 7, 8, 11, 12 12,13 & 15 30/05/06 4 7, 14 & 38 12, 13 & 15 30/04/06 5 16 22 30/03/06 Chilton Court Residential Home Version 5.1 Page 23 6 16 22 7 29 19 Sch 2 18 8 30 9 30 & 18 13 & 18 10 30 & 4 13 & 18 11 31 & 32 17(2) Sch 4 (6) 12 33 24 13 36 18(2) 14 38 12 & 13 15 27 & 38 18(1)(a) Regulation 22 of The Care Homes Regulations 2001. This is a repeat requirement. The Registered Manager must ensure that the complaints procedure is given to all residents. This is a repeat requirement. The Registered Manager must ensure that full and satisfactory information is held for all staff employed at the home. The Registered Provider must ensure that all staff receive training appropriate to the work they are to perform. The Registered Manager must ensure that all staff undertake training in the protection of vulnerable adults. The Registered Manager must ensure that staff working with residents with dementia are appropriately trained. The Registered Provider must ensure that the general manager has a job description in place and there are clear lines of accountability within the home. The Registered Manager must establish and maintain a system for reviewing and improving the quality of care at appropriate intervals. The Registered Persons must ensure that all staff employed at the home are appropriately supervised. The Registered Manager must ensure that a risk assessment is in place to ensure that the home is safe and secure for those residents who may unknowingly place themselves at risk. This is a repeat requirement. The Registered Manager must evidence that reviews of staffing levels for all shifts are DS0000024357.V283106.R01.S.doc 30/03/06 17/03/06 30/05/06 30/05/06 30/05/06 30/03/06 30/04/06 30/04/06 30/03/06 30/03/06 Chilton Court Residential Home Version 5.1 Page 24 undertaken. This must be clearly linked to dependency levels and ensure that the homes ratio of staff to residents effectively meets residents needs at all times. This is a repeat requirement. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard 9 3 16 Good Practice Recommendations Medication Administration Records should include a photograph to ensure residents are correctly identified. Pre admission assessments should be developed so that they are appropriately detailed and provide the foundation of a care plan. All complaints received by the home should be recorded in the ‘complaints log’ together with evidence that they have been appropriately investigated and responded to. Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Chilton Court Residential Home DS0000024357.V283106.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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