Inspection on 15/11/06 for Chilworth House

This inspection was carried out on 15th November 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chilworth House 01/02/10

Chilworth House 18/11/09

Chilworth House 20/01/09

Chilworth House 20/05/08

Chilworth House 14/11/07

Chilworth House 19/12/05

Chilworth House 04/08/05

Chilworth House 13/01/05

Chilworth House 02/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Chilworth House 7 Rectory Avenue High Wycombe Bucks HP13 6HN Lead Inspector Gill Wooldridge Unannounced Inspection 15th November 2006 09:30 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 Chilworth House DS0000022964.V295028.R02.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. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chilworth House Address 7 Rectory Avenue High Wycombe Bucks HP13 6HN 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) 01494 526867 01494 526140 simon@lloydscott-healthcare.co.uk Lloyd Scott Healthcare Limited Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Chilworth House is a care home providing personal care and accommodation for 29 older people. It is privately owned. The home is situated in High Wycombe and is a short drive away from the amenities that a large town can offer. The home has been owned and operated by Lloyd Scott Healthcare since 1998 and has undergone many improvements since then. It is a well maintained Edwardian building and the improvements are in keeping with the style of the building. There are 26 single bedrooms and two double rooms, which are comfortably furnished. The home has two lounges and a pleasant conservatory. There is a sheltered outside sitting area and well kept garden. There is an experienced staff team. The fees for the home are from £420.00 for a single en-suite room. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the annual key inspection visit carried out by Gill Wooldridge (inspector) on 7th November with a follow up visit on the 15th November 2006. The inspection consisted of the following: An assessment of information available to the Commission since the last inspection visit. Comment cards were received from six relatives and from seven residents. Residents and relatives were spoken with during the inspection and their comments are reflected throughout the report. An assessment was made against requirements made at the previous inspection visit in December 2005 and against the key standards. Documentation was viewed and residents care tracked. Staff practice and staff interactions with residents were observed. There were also discussions with a number of staff, the acting manager and the proprietor. A tour of the building was carried out and lunch was sampled. What the service does well: Residents are encouraged to maintain contact with family and friends who are welcomed in the home at all times. Residents were served a well presented meal that appeared nutritionally balanced and menus generally take into account different likes and dislikes. Medication records were generally completed to a satisfactory standard. The home operates a clear induction system. The proprietor regularly carried out Regulation 26 visits and maintains these records. The residents described being satisfied with the care they receive from staff. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 6 The residents were well presented and the home was generally clean. The home has responded to a concern satisfactorily putting in systems to ensure practice is improved. What has improved since the last inspection? What they could do better: All assessments must be completed and reassessments carried out as appropriate. Care plans lack the detail to ensure that residents’ personal health and social, emotional and recreational needs are met fully. Risk assessments must be reviewed regularly and following a fall or accident. There needs to be a protocol in place for staff to follow regarding any head injury. Staff must be informed as part of their induction regarding best practice. Hand written entries on MAR sheets should be supported by two staff signatures and all prescribed medications should be signed for. Some residents and relatives feel that residents need more stimulation. All radiator covers which do not fully cover the radiator must be risk assessed and this system monitored to ensure that it does not pose a risk to residents. All door opening devices used in the home must be approved by the fire department and risk asessed. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 7 All bedrooms windows accessible to residents and small children visiting the home must be risk assessed in consultation with the environmental health department and fitted with appropriate closure devices. Records of hot water temperatures should be maintained. Adult protection training and fire safety training has not been completed for all staff. The manager confirmed that she has booked staff on these training courses in the coming months. Recruitment procedures must be more robust. 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. Chilworth House DS0000022964.V295028.R02.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 Chilworth House DS0000022964.V295028.R02.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Some shortfalls in the assessment documentation could lead to verbal exchanges of information being lost which could affect the residents’ service delivery. EVIDENCE: This group of standards was assessed through discussion with the acting manager, viewing documentation and evidence of residents’/relatives’ involvement in the admission process. Pre-admission assessments were viewed for three residents admitted to the home in recent weeks. Two assessments were not completed fully and the manager agreed to ensure that all documentation relating to the residents’ assessment was completed within 48 hours. The manager confirmed this in writing to the Commission following the inspection, and during the follow up visit records seen were more complete. It is acknowledged that one resident was admitted to the home on the day before the inspection. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 10 Other residents were described by staff as needing nursing care. Good practice guidelines were discussed regarding the admission process with the acting manager and these need to be developed to support the process. The manager has gained information from a social worker to aid in the development of the process of admission. Residents described being settled in their new home and the manager stated that prospective residents, their relatives and/or their representatives are encouraged to view the home. Some good information was received from a hospital along with the medication prescribed which aids the assessment process and this is noted as good practice. Residents’ files case-tracked had a contract and terms and conditions of their stay on file. Chilworth House DS0000022964.V295028.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are generally good systems for recording medication administered which should not place residents at risk. EVIDENCE: This group of standards was assessed through discussions with the deputy manger, viewing documentation and evidence of involvement in the care planning process for five residents, observations of care delivery and discussions with some residents. Of the five care plans viewed, records seen indicated that the acting manager had put basic care plans in place. These documents still need further work. The acting manager had asked a district nurse to support the staff through training in catheter care. Staff confirmed this training. Staff practice observed was good but this information needs to form part of the care plan and the manager needs to ensure that all staff are aware of best practice. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 12 Two residents had facial bruising; both were explained by staff and the resident, where able. One resident’s bruise to their face was described by a relative, and they stated that the GP had not been called immediately. The relative said that after prompting staff had called the doctor on call and he/she advised an x-ray. It is strongly recommended that the manager develops a protocol for head injuries and staff clearly record their actions to follow up any concerns and ensure that a GP is called following a head injury. It is acknowledged that the acting manager described good practice of informing relatives and that a review of this system is in hand. The acting manager has been booked on a first aid course. Health information is held in the care plan file, and residents’ records indicated that they are supported by a range of health professionals, for example chiropody and the district nursing service. One concern noted was the number of falls recorded within the home. It is strongly recommended that professional advice be sought regarding falls prevention and that the acting manager develops an audit system. Tissue viability and nutritional screening had not been assessed fully and developed into a care plan. It is acknowledged that the district nursing service supports the care of residents with pressure sores. The acting manager stated that only one resident has a pressure area or dressings. Following the inspection one member of staff had attended a training session held by a team of tissue viability nurses. It is hoped that this will improve practice in the home. Privacy and dignity was generally observed and staff were overheard knocking on residents’ bedroom doors and waiting permission to enter. Staff practice indicates that they respect residents’ individuality and residents and relatives confirmed that their privacy is respected. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ routines and choices are respected, which ensures that residents can pursue their own interests whilst participating in occasional communal, religious or group recreational activity if desired. Visitors are welcome at any time which means that residents maintain contact with friends and families. Menus take into account residents’ different likes and dislikes. EVIDENCE: Residents described that their preferred routines are respected and that they are free to exercise choice in relation to meals and activities. Activities described by residents included watching the television, listening to the radio or music, reading the paper, reading a book, doing a puzzle or playing dominoes or cards. Staff are deployed in the afternoon to arrange activities which seemed to be enjoyed by the residents. The home also offers a massage service, which residents described as helping their well being. Staff have had training to carry out this task. There is a nominal charge for this service. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 14 Festivals and special days are celebrated. Some residents and relatives commented that there could be more stimulation. The manager plans to address this issue. Activities take place in the afternoon and sometimes in the late morning, with residents enjoying these sessions. A church service was taking place during the inspection on one morning. At the follow-up visit a late afternoon activity was obviously enjoyed by residents, with the entertainers encouraging residents to participate. Residents’ interests should be recorded in their care plans. Most residents have family or other links with the local area. Relatives generally praised the service. Some concerns are discussed in other areas of the report. One resident described being 102 and described needing her care to be gentle. Staff seem to have taken this on board. The detail of this resident’s care must be clearly documented. Residents may have visitors at any time. Visitors attend most days. Visitors spoken with confirmed that they were made to feel welcome and those visitors seen during the inspection were offered a cup of tea. Meals are freshly prepared by the cook who has been in post for some time. The food was attractively presented and tasty with two fresh vegetables, followed by dessert. Breakfast is served in residents’ bedrooms if requested and residents seem happy with this arrangement. They described this as an unhurried start to the day. One staff member described taking residents a cup of tea before they start their personal care. Lunch is the main meal of the day and is served at around 12. 30pm. Drinks were seen to be offered to residents regularly with cakes, biscuits and fresh fruit offered as well. A number of residents have their meals in the dining area. A choice of drinks is provided with all meals and on request. Alternative choices for menus are highlighted with the chef. Where residents cannot act for themselves, either a family member or care manager holds that responsibility. The acting manager stated that an advocacy agency is advertised in the home. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 15 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 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit. The home’s complaints procedures should ensure that residents or others making complaints have their concerns addressed. The home’s adult protection procedures need to be supported by training which should then ensure that residents are protected from harm. EVIDENCE: The home has received one concern since the previous inspection, and the relative was encouraged to put their concerns in writing as they didn’t wish to complain. This concern was handled appropriately and the proprietor described actions to improve the service delivery. No complaints have been received or addressed to the Commission since the previous inspection. The proprietor and acting manager must ensure that all staff attend adult protection training. This is a requirement of this report. It is acknowledged that staff spoken with confirmed that they would report any potential, actual or suspected abuse. Residents stated that they never hear staff raise their voices. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 16 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, 26 The quality in this outcome area is good. This judgement has been made using available evidence including a site visit. The home is warm, well furnished and well maintained and generally provides a comfortable environment for residents with a range of needs and abilities. All radiators must have a low surface temperature or be covered if residents are to be protected from accidental falls and burns. An odour in one bedroom must be eliminated to ensure that residents have a pleasant environment. EVIDENCE: The home is a pleasant, large detached house a short distance from the town of High Wycombe. Access is easy by car and the area is served by buses and a train service. There is ample car parking space to the front and a pleasant, medium sized garden to the rear. The house is warm, well furnished, generally clean and tidy, and well maintained. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 17 Communal space consists of two lounges, a dining area and a conservatory which looks onto the garden. There are fans in place to support the ventilation in this area in any hot spell of weather. The garden has a small patio area which is used in warm weather. The lighting is domestic in character and furnishings are of good quality and suitable for purpose. There are 30 bedrooms - 28 single and two-shared. The home is pleasantly decorated and bedrooms are warm, well furnished and have been personalised by residents. One bedroom had an odour and this must be eliminated. Housekeeping staff are to be commended for their hard work in maintaining the cleanliness of the building and it is acknowledged that the odour referred to needs to be placed in context with the resident’s complex needs. The home has equipment appropriate for the needs of residents. This includes a lift to the first floor, grab rails in key locations, raised toilet seats, a ‘Parker’ bath, a hoist and wheelchairs. Risk assessments need to be in place to support the care of residents when staff are moving and handling in a confined space. Heating and lighting are effective and suitable for their purpose. Three radiators were not covered on the first day of the inspection. Two radiators had been covered by the follow-up visit and the proprietor explained that the third radiator cover would be replaced when the decoration of the bedroom is complete. A number of radiators in the communal areas and some bedrooms were not completely covered, but fitted with ply wood which had been fretted and fitted to the radiator. These must be risk assessed to ensure that the acting manager and proprietor are monitoring the effectiveness of these covers. There are sufficient facilities for washing hands on both floors. Liquid soap and paper towels are in use. The temperature of the hot water in outlets to which residents have access has been regulated to 43 degrees Celsius. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not operate a robust recruitment procedure, which could place residents at risk. Shortfalls in training and supervision could have an impact on the health and safety of residents. The staff rota indicated that staff shortages might impact on resident care. EVIDENCE: This group of standards was assessed through discussions with residents, staff, the acting manager and through observations of staff practice and documentary evidence. The manger confirmed that staff had not completed fire training and adult protection training, and this was confirmed by staff spoken with. However, the manager stated that she has booked staff on these training courses in the coming months. All newly appointed staff will need to complete their mandatory training within six months. It is strongly recommended that the acting manager develops a training matrix. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 19 Staffing levels appeared to be adequate at the time of the inspection. However, it was discussed with the acting manager that the needs of the current resident group are ever changing and staffing numbers should be reviewed continuously. It was confirmed that extra staff would be on duty should the need arise. From studying the staff rota, and discussions with residents and relatives, it is evident that the home occasionally is not able to maintain its staffing levels at the weekends due to sickness. The acting manager needs to have a contingency plan in place to ensure that residents’ care is not compromised if there is staff sickness. Two new staff have been recently employed and they are supporting an established staff team. Staff personnel files were viewed and indicated that the proprietor and acting manager do not have a robust recruitment procedure to ensure the protection of residents. Omissions included references, CRB and PoVA First checks. Following the inspection the proprietor has written to the Commission stating that the PoVA First check should be returned ‘by the end of the week’. The proprietor also confirmed that there is a half-completed policy and procedure to support the safe recruitment of staff which will be fully developed and implemented. The proprietor confirmed that newly appointed staff are working supervised until the CRB and PoVA First checks and written references are in place. Staff have a clear induction which should be supported by ‘Skills for Care’, formally TOPPS induction. A senior induction pack outlining staff responsibilities should also be developed. Formal supervision is not consistently in place; this was confirmed by the manager and staff. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The acting manager, although relatively new in post, demonstrates a proactive approach which should benefit the development of systems and therefore the care of residents. Further work is needed in developing audit systems including health and safety and care plans, and ensuring that requirements set previously are acted upon in a timely manner. This will support the care of residents. Residents’ financial interests are supported by a clear system. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 21 EVIDENCE: This group of standards was assessed through discussions with the acting manager, staff on duty and through observations and documentary evidence. The current management of the home shows good leadership and support which impacts positively on service users. The acting manager has been in post for a number of weeks and found herself responsible for the inspection. The proprietor and previous manager are responsible for a number of the shortfalls noted in the report. It is hoped that the acting manager and proprietor will address all the points detailed in the report and some evidence of their proactive approach was evident in the time between the inspection and follow up-visit. The acting manager will need to register with the Commission in the coming weeks and it is strongly recommended that the proprietor appoint a deputy manager to support the acting manager in her role. A clear job description and regular supervision for the acting manager will support this transition. The proprietor records Regulation 26 visits, visiting the home regularly and talking with residents, relatives and staff. Care is taken to ensure that service users’ finances are protected by safe storage of personal monies. Policies and procedures are written with the the focus on service users rights’, and most of these were up to date and practiced. However, formal supervision is not consistently in place. This was confirmed by the manager and staff. It is strongly recommended that the proprietor and acting manager ensure that there is a programme of supervision for all staff. A fire risk assessment was noted to be in place along with servicing and regular fire call point checks being carried out. Records seen showed that a portable appliance test took place in February 2006. The acting manager stated that the lifts and hoists are tested regularly and this was confirmed in the pre inspection questionnaire. A system is in place to inspect the water tanks and hot water cylinders and the proprietor stated that the home had had a new boiler in recent months. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 18 (1) (a) Requirement The proprietor and acting manager must ensure that all staff are trained in adult protection. The proprietor and acting manager must ensure that door guards, or any other device used to hold open bedroom doors, are risk assessed and supported by approval from the fire officer. The proprietor must ensure that copies of the information required by Regulation 19, Schedules 2 and 4 of the Care Homes Regulations 2001 are in every staff member’s file. The proprietor and acting manager must ensure that all staff attend fire safety training. Timescale for action 31/03/07 2 OP19 13 (4) (a & c) 31/01/07 3 OP29 19 Schedule 2&4 31/01/07 4 OP30 18 (1) (a) 31/03/07 Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 24 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 OP7 OP7 Good Practice Recommendations It is strongly recommended that the acting manager develops a protocol for head injury, ensuring that all staff are aware of the actions that must be taken. It is strongly recommended that the acting manager audits all falls and that professional advice be sought regarding falls prevention. Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, 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 Chilworth House DS0000022964.V295028.R02.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!