Inspection on 27/09/05 for Chilton Meadows Residential & Nursing Home

This inspection was carried out on 27th September 2005.

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

The inspector 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

Chilton Meadows Residential &... 17/01/08

Chilton Meadows Residential &... 22/01/07

Chilton Meadows Residential &... 05/01/06

Chilton Meadows Residential &... 15/12/04

Chilton Meadows Residential &... 30/06/04

Chilton Meadows Residential &... 01/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Chilton Meadows/Gainsborough Hse Residential & Nursing Home Union Road Onehouse Stowmarket Suffolk IP14 1HL Lead Inspector Jill Clarke Second Inspector – Jess Scotford. Announced 27th & 28th September 2005 10:00 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 Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chilton Meadows/Gainsborough Hse Residential & Nursing Home Union Road Onehouse Stowmarket Suffolk IP14 1HL 01449 770321 01449 614248 Address 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) BUPA Care Homes Limited Mrs Karen Patricia Earnshaw Care Home 120 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (90) of places Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2004 Brief Description of the Service: Chilton Meadows is a purpose built care home, situated close (approximately a mile) to the town centre of Stowmarket. Stowmarket has a range of facilities, which include Post Office, banks, shops, cafés, cinema, rail and bus links. Chilton Meadows can accommodate up to 120 older people in four houses, each of which provides 30 bedrooms. Two Houses - Constable and Munnings, provide nursing care for very dependent residents, many of whom use wheelchairs. Beech House provides dementia and nursing care, for people who are mentally frail. The fourth house, known as Gainsborough, provides care for older people, who do not require nursing or dementia care. All houses have a small kitchen, lounge/dining area, with a patio leading out to well maintain gardens. All bedrooms are of single occupancy, and are situation close to the communal toilets, and bathrooms. Although known as ‘houses’ the resident’s accommodation is built on ground level, with wheelchair access throughout. The administration part of the complex is built on 2 floors, and houses the offices, hairdresser, laundry, main kitchen, reception area and training rooms. All areas that the residents would need to access are located on the ground floor. The home has it’s own mini bus, and on-site Activities Organisers. Whilst the entire home is the responsibility of the Matron, Mrs Karen Earnshaw, each house has its own manager/Senior Sister who is responsible to Mrs Earnshaw for the daily care of residents and supervision of staff. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine announced inspection carried out by 2 inspectors over 2 weekdays (between 10am and 4pm) in September. The inspectors spent an average of ½ a day on each of the 4 houses (Munnings, Constable, Beech and Gainsborough) to be able to give a more balanced view. During the inspection, time was spent talking with 35 residents (12 in private) and 6 visiting relatives. Time was also spent with members of staff, which included the Registered Manager, Senior Sisters, House Manager, Laundry Assistants, Catering Staff, Maintenance person, Clerical and Care Assistants. The day following the inspection, contact was made with a representative of ‘Suffolk Fire and Rescue Service’, to seek further guidance on Fire door closures. Commission for Social Care Inspection (CSCI) feedback cards were sent to the home before the inspection. This gave an opportunity for relatives, visitors and staff to give feedback on how they thought the service was run. Comments from the completed 16 resident, 4 relative, and 29 staff feedback cards, have been included in this report. On each on the 4 houses, the environmental tour took in the lounge/dining room, sluice, and a sample of 1 bathroom, 2 toilets and 5 bedrooms. Time was also spent in the administration building, looking at the laundry and training room. Paperwork looked at, included pre-admission assessments, care plans, staff rotas and supervision records, training plans, quality assurance analysis, recruitment and medication records. Discussions throughout the day identified that people living in the home preferred to be known as residents. This report reflects their wishes. What the service does well: Residents comments on the home included, “very nice here”, “quite happy here”, “very well run”, “excellent laundry service” “always clean”, and “so attentive – can’t speak too highly of the staff”. A relative praised the care saying when they went home they knew the residents “were being well looked after”. Relatives said that they are made to feel welcome. Residents are encouraged to take part in a range of activities. The home is committed to the training and development of their staff, to ensure they have the skills, and knowledge, to carry out their work. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 6 Staff felt they “work well as a team” and fell supported by the management. What has improved since the last inspection? What they could do better: 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 Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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): 2, 3, 4 and 5. People wishing to move into the home, can expect their needs to be fully assessed. However the home, although they have identified that they can meet the persons needs, must ensure they do not admit outside their registration category. EVIDENCE: A copy of the ‘Resident information’ file was seen in the bedrooms. This gave a good level of information, which included meal times, Doctors visits, and the home’s ‘Philosophy of Care’. On the back of the bedroom doors was the name of the residents ‘Named Nurse’ and ‘Key-worker’. These are members of staff who oversee the resident’s care, and update their care records (care plans). Before the inspection, the home was asked to provide details of how many residents had a diagnosis of dementia. The numbers given, exceeded the number that the home was registered for. The manager said that this was where residents who required nursing care, also had a secondary diagnosis of dementia. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 9 This led to discussions that the home had recorded that they had 5 people with a diagnosis of dementia living on Gainsborough House, which is residential and not nursing. It was not clear if the people completing the form for Gainsborough, had taken their own view as to the resident having dementia, or if it was taken from medical or admission notes. Discussions with staff on Gainsborough House identified the names of 2 residents, whose mental health needs have changed, and were being reassessed. The home was asked to re-assess all the residents (who were not looked after in Beech House (Dementia Care), to find out how many had a diagnosis of dementia. Once identified, they must apply to the CSCI, to increase the number of people they are registered to care for, with a diagnosis of dementia. Time was spent talking to a resident, and another resident’s relative, to discuss their different experiences, during the admission process. The resident said that they had previously stayed at the home on short-break care, so they already knew the staff and home well. They felt the time was right to move into residential care, and the home was able to meet their needs. The relative felt that they had been well supported by staff and management, during the admission process. They said after making contact with the home, they came and looked around, and staff answered any questions they had. The home then arranged to meet the prospective resident, and carry out their own assessment. This was to ensure that they could provide the level of care the person needed. The resident’s name was then placed on a waiting list, and they were contacted when a vacancy came up. The relative praised the standard of care, and the way staff involves, and supports the family, during, and after admission. They said “there was always someone there to explain things to me”. Care plans looked at, held completed pre-assessments, undertaken by the Manager, before the residents were admitted. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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, 10, and 11. People using the service can expect staff to monitor their care, and respect their right to privacy. EVIDENCE: During the inspection, 3 residents care were ‘tracked’ on each of the houses. This involved looking at care plans, and spending time with the resident (where possible) and relative - if visiting, to discuss their views on the level of care provided. Time was also spent with staff on each house; to discuss their knowledge of the residents, individual care needs. Since the last inspection the home had changed the layout of their care plans. They were found to be easy to read, and reflected the level of support residents (or their relatives) said was required. The care plans contained information on residents, physical, social and mental health care needs. Staff had identified any risk to the resident’s safety, and recorded what action they were taking/taken, to reduce, or eliminate the risk. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 11 One manual handling assessment sheet instructed ‘2 staff to hold’ the resident ‘on both sides’. It did not give, further information on how staff should ‘hold the resident’. Some care plans looked at held an ‘audit sheet’, which the manager had completed. This was carried out as part of the home’s quality monitoring control systems, to ensure the care plans had been fully completed and updated. This included any contact made with external Health Professionals (Doctors, Consultants, Occupational Therapist, Physiotherapist, Nutritionist) to support residents care needs. Residents care plans looked at held copies of Behavioural Assessment Scale of Later Life (BASOLL). Staff said they complete the assessments on admission, then review, and update the information monthly. This supports the staff in monitoring any changes in a resident’s mental health and if applicable seeking further advice. Other monitoring sheets held in the care plans, covered the residents diet intake, mobility, condition of their skin, catheter care, and support needed with personal care. One resident’s oral health assessment recorded that the person refused to wear their dentures. Discussion with the resident’s relative, identified that although this was correct at the time of admission, the home had since arranged for new dentures to be fitted. These were more comfortable’ and the resident was now wearing them. Time was spent with a relative looking at their next-of-kin’s care plan, as the resident them self was unable to communicate their wishes fully. This gave the relative a chance to see what support was being given, and to gain their views if they felt the information was accurate. They said that they had not seen the care plan before, but felt it gave a good level of information, and covered the support they felt the resident needed. Although residents or relatives signatures were seen on risk assessments and statements saying they had been involved in developing the care plan. Some residents and relatives spoken with had not seen the care plan, although remembered signing a risk assessment. Care plans held a ‘Spiritual needs assessment’, which asked residents if they had any concerns or worries about dying, for example being in pain or fear of being alone. One care plan was viewed and the resident had answered ‘pain’. Residents were also asked about their religious beliefs, and covered what they would want following death (cremation, burial, name of funeral directors). Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 and 14. People using the service can expect to be treated with respect by staff, and supported to take part in a range of activities. Visiting is flexible, and visitors are made to feel welcome. EVIDENCE: Time spent with relatives confirmed that they felt comfortable to visit whenever they wanted. This was also reflected in the CSCI residents feedback cards and letters sent to the houses. One thank you card stated ‘not only did you look after (residents name), you also looked after us as a family as well’. Each House had a list of the week’s activities, for both mornings and afternoons displayed, which also gave information on which houses they were taking place. Each month the home also books entertainers to come into the home. The CSCI feedback cards asked residents if the home provided suitable activities, 15 out of the 16 said ‘yes ‘and 1 said ‘sometimes’. Activities taking place during the inspection included church service, bingo and collage making. Time was spent with the residents on Gainsborough House, as they made collages out of the photographs they had taken during the summer, at various activities and social functions. Forthcoming functions included a ‘Think Pink Day’ on the 14th October, in aid of Cancer. Staff and Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 13 residents were discussing their dress code for the day – which they aimed to be mainly pink!. Activities arranged by the Activity co-ordinators, were recorded resident’s ‘social activity sheets’. One resident, when asked about activities said “entertainment side quite good – arrange outings”. Another resident said that 4 to 5 from each house went on an outing to Lowestoft, which they enjoyed. One relative felt that Beech House did not “seem to have a lot of activities” and that it “would be nice to take residents out in a wheelchair”. This was fed back to the Senior Sister, who said that staff do spend 1 to 1 time with residents, but was not recorded on the social activity sheets. They went on to say, that the sheets are completed by the Activity co-ordinators, only list activities undertaken with them – not staff on the houses. Further discussion identified that the residents due to their dementia, may not always remember what activities they had joined in with. It was suggested that staff could write this into the residents care plan, so relatives would know what support they had been given by staff on the houses. The inspectors were given a copy of the homes ‘War-time facts and memories as supplied by our residents and their relatives’ (July 2005). This was produced with the residents and relatives as part of the ‘nation’s Biggest Thank You’. The 23-page booklet gave feedback from residents and relatives on what it was like living during the war. It contained photographs of residents as they were then, dressed in their service uniform. The home also held a party for residents on the 10 July 2005, as part of the celebrations, which they said most of the residents attended. A resident felt that that they did not have to fit in with the homes routines, they said they liked to stay up late and watch a movie. When they were ready for bed they would call for the staff to help them. They went on to say they could be left alone if they wanted, as “staff won’t come in - unless we call them”. If required, the ‘Residents information file’ held information and contact numbers of local Advocacy services. During the inspection, relatives were seen gardening and building a ‘Chipmunk enclosure’. Staff said that relatives supported the different houses, by fund raising, and helping them develop new projects, such as putting in a pond. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 and 18. People living at the home, can expect any concerns they have to be listened to, and acted on in an appropriate manner. EVIDENCE: Residents and relatives spoken to during the inspection said that they felt comfortable to raise any concerns directly with staff. The home’s complaints policy was on display in each of the units. A copy of the complaints policy is also included in the residents information file, kept in the bedrooms. One resident said that the “Matron comes around at least once a week to see if there are any complaints”. They felt this was a good idea, and gave a chance for people to air their views direct - if they wanted to. Time was spent with the manager looking at complaints, which had been received by the home. Records showed that the home had taken appropriate action, within the required timescales. The 29 staff who had completed the CSCI comment cards, had all confirmed that they had received training in identifying and reporting abuse. This was further confirmed during discussions with staff during the inspection, and staff training records. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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): 19,20,21,24,25 and 26. People using the service can expect a comfortable, environment to live in, which suits their needs. Although some areas are showing wear and tear, this will be addressed as part of the home’s on-going maintenance and refurbishment programme. EVIDENCE: All 4 houses were found to be clean and odour free. A resident asked if the home was normally this clean, taking into account it was an announced inspection replied “ the domestic staff are marvellous – come in and wash the room out every day – nothing too much trouble”. One relative spoken to, felt that the home was generally kept clean, although there was “occasional smell”. From the sample of bedrooms looked at, all were found to be clean and odour free, although it was noted that one carpet had not been vacuumed under the bed. On Beech House, staff places the commode pots on racks, ready for use after they have been put through the sterilise/washer. On close examination 2 of Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 16 the commode pots, still had what looked like dried faeces on the rim of the pot. This led to discussions with staff, over the need to ensure as part of the homes infection control procedures, that the pots are thoroughly cleaned and checked. Residents bedrooms looked at were personalised with family photographs, pictures, ornaments and some had their own televisions. Residents spoken to said that the room was furnished to meet their needs. It was noted that some residents had adjustable beds. Staff were asked if they felt they had sufficient adjustable beds to support residents mobility and nursing care needs. They said that they felt they had enough at the moment, as they had moved beds around. However, they did feel that the home could benefit from having extra adjustable beds, to cover residents whose needs may change quickly. On Beech House (Dementia care unit) ‘memory boxes’ had been fitted on the walls in the bedrooms. Staff said they were working with residents to identify the memorabilia that they would like to store in them. Some of the corridors paintwork on the houses were showing signs of wear and tear. The manager confirmed that this would be addressed during the winter as part of the on-going maintenance programme. The 4 houses had each arranged the furniture in communal areas differently, to give more individualism and character to the house. The dining rooms had a range of tables, which were suitable for both wheelchair, and non-wheelchair users. The grounds were very well maintained and attractively laid out with the recent addition of a water feature and summerhouse. Residents confirmed their enjoyment of the outside facilities and ease of access to the grounds. The hot water supply to 1 hand basin in Beech House was left to run for 4 minutes, but was still cold. Staff said they had problems at times, but if run long enough the hot water would come through. Concerns were raised that a resident wanting to wash their hands would not want to wait. Time spent with 1 relative identified that there had been problems at other times, as they had found the hot water cold, and staff had brought them some hot water. Staff said that parts of the boiler system had been changed, and other work is due to be carried out, as part of the home’s on-going maintenance plan. Time spent in the homes ‘in-house’ laundry, showed that it was well organised, and had methods in place to reduce the risk of lost laundry, which included their own labelling machine. Residents and relatives spoken to, were happy with the standard of laundry, especially taking into account it was such a large home (120 residents). Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 and 30. People using this service can expect staff to be well trained, and have the skills and knowledge to undertake their job. EVIDENCE: Staff rotas looked at showed that there should be enough staff on duty, on each of the houses to meet the needs of the residents. The Activity Coordinators hours were in addition to the Care and Nursing hours provided. All of the residents (16) who had completed the CSCI comment cards, had ticked ‘yes’ when asked if they felt they were ‘well cared for?’. This was further reflected during conversations with residents during the inspection. Residents felt that staffing levels were generally adequate and met their needs. However 1 resident raised their concerns over the staffing levels at night, and felt that there should be more – as there “so many patients in bed” for staff to look after. Further discussion confirmed that staff came when they rang the call bell, and they had never been left waiting. Rotas showed that the staffing levels at night were 1 Nurse and 2 Care Assistants. Staff said that they could also call on the other houses in an emergency. Relatives completing the CSCI comment card, felt that there were always sufficient numbers of staff on duty. However, 1 relative on Beech house had Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 18 noticed that 4 –5 staff tended to take their breaks together. They felt this reduced the staffing levels and wondered if they should be more ‘staggered’. The home has a Training co-ordinator, who monitors all staff training, including induction. Time spent with 8 members of staff, confirmed that the home had a good training programme. They said that all received paid mandatory training such as Fire, Manual Handling and Food Hygiene. Staff said that they also receive regular training updates, and additional relevant training. Examples given were ear syringing, taking bloods and undertaking male catheterisation. All 29 staff that completed the CSCI comment cards had ticked ‘yes’ when asked if the home had a good training and development programme to support staff. Forthcoming training notices were displayed in the offices, along with information sheets, to keep Nurses professional knowledge updated. Records of 4 recently recruited staff were looked at. Records held confirmed that the home had undertaken checks, and obtained paperwork to prove the new employee’s identity - before they started work at the home. However it was identified that the home had not obtained a Criminals Records Bureau (CRB) check for volunteers. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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): 32, 33, 36 and 38. The home is well run; staff feel supported and are committed to providing a good level of service. To ensure the safety of residents, the home must update their Fire Policies and staff practices. EVIDENCE: General discussions with residents, relatives and staff, confirmed that they felt the home was well run. They felt that the “Matron” (registered manager) and senior staff were approachable, and listen to any concerns. One resident who was asked if they felt the home was well run said “yes”. They went on to say they spoke regularly to the matron, and “that nothing misses the eye of the Sister in charge” of the house. Comments made by 1 member of staff on their feedback card said that the person in charge of the ‘house’, “ worked hard to achieve a good standard and Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 20 we all work as a team”. Another member of staff had written that I “am more than happy with my job”. This was reflected during conversations with staff over the 2 days, who also said they had a “good stable team”. The homes newsletter ‘Chilton Chatterbox’, keeps residents, relatives, visitors and staff up to date on what’s happening at the home. This included feedback from CSCI inspections and the homes own quality assurance ‘satisfaction surveys’. Where residents/relatives had raised any concerns, the newsletter said how they were going to address it. The newsletter also gave information on any staff changes, planned events and functions. The newsletter was available for people around the home. Time spent with residents and relatives, confirmed that they had read the newsletter, with 1 resident saying “it kept them up to date”. All staff who had completed the feedback cards, had confirmed that they received regular 1 to 1 supervision with senior staff. This was also confirmed during interviews with staff, and by looking at signed, completed supervision records held securely in the office. During the environmental tour, it was noted that some bedroom doors were held open with beanbags. The main kitchen and laundry fire doors, both high risk areas where fires could start, were held back by cans or door wedges, and could not self-close if the fire alarms were set off. Part of the fire safety strip/seal to the kitchen door had come unstuck. Part of the safety strip/seal to the fire doors between the kitchen and laundry room was missing. Once pointed out the home took immediate action during the inspection to replace the missing strip/seals, and remove the door wedges to the laundry and kitchen. Staff were concerned that removing the beanbags, used to hold back bedroom doors, would restrict resident’s movement and may cause distress. The day after the inspection, the CSCI contacted the Suffolk Fire and Rescue Service. The duty Station Fire Officer confirmed, to ensure residents’ safety, doorstops must be removed. A letter was sent to the home, asking for the doorstops to be removed. The home was ask to look at an alternate method of holding residents doors open, which would meet fire regulations. Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 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 x 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 x x 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x x 3 x 2 Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP4 Regulation 14, 16 Requirement The home must re-assess all their residents to identify who has a diagnosis of dementia on Gainsborough, Constable and Munnings Houses. Once completed, the home must submit an application to increase their registered numbers for people with dementia. The home must write to the Commission stating what action (including timescales) is being taken to address the problems with the home’s hot water supply. The home must ensure that commode pots are kept clean and hygienic. All fire doors must be checked to ensure they comply with Fire Safety Standards. To ensure the safety of people living/working at the home, Fire and resident bedroom doors must not be ‘wedged’ open. Where a resident has requested that their bedroom door is kept DS0000024359.V254040.R01.S.doc Timescale for action 01/12/05 2 OP21 23 (2) (j) 01/12/05 3 4 OP26 OP38 13 (3) 23 (4) 31/10/05 29/09/05 5 OP38 23 (4) 13 (4) 29/09/05 Chilton Meadows/Gainsborough Hse Residential & Nursing Home Version 5.0 Page 23 open, an automatic closing device must be fitted, which meets fire safety requirements. 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 OP7 Good Practice Recommendations Although residents and relatives spoken to, were aware that they had signed a risk assessment or care plan sheet on admission – some were unaware of all the other information held in the care plan. The home should ensure that residents, and/or their representative are not just given a risk assessment to sign, but given the whole care plan to look at if they wish. Where the home uses words such as ‘hold’ on manual handling assessments – giving staff clear guidelines on how this should be undertaken, should follow this. 2 OP8 Chilton Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 24 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 Meadows/Gainsborough Hse Residential & Nursing Home DS0000024359.V254040.R01.S.doc Version 5.0 Page 25 - 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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