Inspection on 18/11/09 for Chilworth House

This inspection was carried out on 18th November 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC 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 20/01/09

Chilworth House 20/05/08

Chilworth House 14/11/07

Chilworth House 15/11/06

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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Chilworth House 7 Rectory Avenue High Wycombe Buckinghamshire HP13 6HN Lead Inspector Barbara Mulligan Key Unannounced Inspection 18th November 2009 09:30 DS0000022964.V378536.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chilworth House Address 7 Rectory Avenue High Wycombe Buckinghamshire 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 www.chilworthhouse.com Lloyd Scott Healthcare Ltd Susan Cook Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 29. Date of last inspection 20th January 2009 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. The bedrooms are comfortably furnished and residents can personalise their rooms with their own furniture and personal belongings. The home has two lounges and a pleasant conservatory. There is a sheltered outside sitting area and well-kept garden. The fees for the home range from £580 per week low dependency to £950 per week high dependency. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for your service is 0* This unannounced key inspection was conducted over the course of a day and covered all the key National Minimum Standards for older people. Prior to the visit, a detailed self-assessment called The Annual Quality Assurance Assessment (AQAA) was sent to the registered manager for completion. The AQAA focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Eighteen surveys were sent to the home but none of these have been received by the Care Quality Commission at the time the report was written. Information received by the Commission since the last inspection was also taken into account. The inspector was Barbara Mulligan. The inspection consisted of discussion with the registered manager of the home, discussion with other staff, opportunities to meet with some people who use the service, examination of some of the homes required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Feedback on the inspection findings and areas needing improvement was given to the registered manager at the end of the inspection. The registered manager, the staff and service users are thanked for their cooperation and hospitality during this unannounced visit. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. There is a motivated and established staff team who respond to service users in a respectful and appropriate manner. The home provides a pleasant and comfortable environment in which people can live. Individuals are encouraged to personalise their rooms with their own furniture and personal belongings. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 6 Communication between people who use the service and staff was observed to be positive and open. The provision of meals and mealtimes are of a good standard. There is a good range of policies and procedures, providing staff with relevant information about all aspects of care and the home/organisation. Health and Safety procedures are in place and records are well maintained. The evidence seen and comments received indicate that this service meets the diverse needs e.g. religious, racial, cultural, disability of individuals within the limits of its Statement of Purpose. What has improved since the last inspection? What they could do better: Where the initial needs assessment has identified a specific need, for example, a person has been assessed to be at risk of developing pressure sores, or a person has been assessed as suffering from anxiety attacks, a plan of care must be developed for staff to follow so they can fully meet that need. Risk assessment documentation must be completed, reviewed and changes made as necessary to ensure staff are working to current information. Clear guidance must be recorded within care plans for the management of as required medicines. The home must ensure they undertake a full investigation all complaints, and the nature of the complaint, the action taken and the outcome of all complaints must be recorded and maintained in the home. The carpet in the identified bedroom must be made safe for the occupant and the windows in bedrooms 11 and 12 must be made safe to open and shut and steps taken to eliminate drafts in these two rooms. Evidence of all recruitment checks for staff must be undertaken before a care worker commences employment and must be made available for inspection purposes. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.2 Page 7 Monthly Regulation 26 reports must be made available for inspection purposes. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 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.V378536.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. Service users needs are assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three completed needs assessments were examined, including those for people new to the home. Each file had a completed needs assessment and showed that all areas and conditions of people using the service were assessed prior to offering them a place in the home. Each assessment contained further information about the persons family and friends, likes, dislikes and preferences. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 10 Alongside each needs assessment there is a section called, “Building a Picture” and asks questions such as, where were you born, what jobs, training or voluntary work have you done, do you have any special memories and where have you lived for the past twenty years. The assessment demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. Each needs assessment was signed and dated by the person completing the initial assessment. The home does not admit service users for intermediate care. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience poor quality outcomes in this area. The health, personal and social care needs of people who use the service are not adequately identified in the care plans, preventing the home from meeting all the needs of the individual. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The care for three people was case tracked and their care plans were examined. At the two previous inspections it was identified that the care plans cover just three main areas. These are mobility, personal hygiene and nutrition. Although these three areas are well documented and provide staff with relevant guidance, the care plans need to be expanded upon to provide information about residents in a holistic way. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 12 In one file examined there was a teeth and denture care plan. However these were not available in the other files seen. Improvements to the care plans since the last inspection include individual preferences, likes and dislikes and reference to end of life care which are recorded in the care plans and describes how these will be met. At the previous inspection one person’s initial needs assessment stated that the individual had depression and anxiety but there were no guidelines for staff to follow about how to support the individual with their depression. A requirement was issued for the identified care needs of people using the service to be detailed in the care plan. The same care plan was examined during this visit and the care plan remains the same. There was no information or management plan in place that tells staff how to support the individual with anxiety and depression. In another file the individual has a specific health need but the care plan does not provide any guidance for staff to support the individual. In one file examined the tissue viability assessment scores the individual as at high risk of developing a pressure sore. There is no information in the care plans about this. Daily notes are detailed and informative and there is evidence that care plans are reviewed monthly. Visual observations of people using this service showed that people were smartly dressed including jewellery, make up and nail varnish, people were seen to be wearing the aids needed, for example hearing aids and clean glasses. Additional support is accessed through the local GP surgeries, where people who use the service can access physiotherapists, occupational therapists and speech therapists. Risk assessment documentation was looked at in the care plans. In each file there is a moving and handling assessment, Waterlow pressure area care assessments, a bath risk assessment and a nutritional assessment. At the previous inspection a requirement was issued for a full nutritional plan of care to be completed for one individual who had diabetes. This has been completed and good nutritional information is recorded in each file. Weights are undertaken and recorded monthly. In the three files examined the initial needs assessment tells us that each individual has a history of falls. Two files do not contain a falls risk assessment and in the third file the falls assessment is dated October 2005. Tissue viability assessments are completed for each person and these are reviewed monthly. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 13 There is evidence in files of optical screening and the registered manager said that dental screening is carried out on a needs only basis. Chiropody Services visit the home on a six weekly basis. The inspector observed staff assisting people who use the service in a kindly and respectful manner. During lunch staff offered service users choices and were polite and patient. Staff are obviously aware of the importance of privacy and dignity and were seen to always knock on doors before entering and always addressing the individual by their preferred term of address. The homes induction programme includes training regarding privacy and dignity. The procedures for the administration of medicines were examined during this inspection. At this visit we looked at the medication administration record (MAR) charts, medication supplies and care plans for the three people whose care was being looked at as part of this inspection, and at the MAR charts for the remaining people using this service. At the previous inspection, numerous gaps and omissions were noted on the Medication Administration Records (MAR) and a requirement was issued for improvement. All Medication Administration Records (MAR) examined were signed by staff when medicines had been given. There were no gaps or omissions on the Medication Administration Records seen. The home was not using any controlled drugs at the time of this visit but they do have the appropriate facilities for this if necessary. There were numerous entries on the Medication Administration Records (MAR) that were hand written. These were not signed or dated by two staff. When it is necessary to handwrite on a medication administration record chart in the home, the member of staff writing the chart should sign and date the chart and a second carer should check the entry for accuracy and then initial the chart. In addition the entry should include a reference to where this information was sourced, such as the prescribers name. At the previous inspection it was noted that there were no written guidelines for many “as required” (PRN) medicines and this is often left up to individual care staff’s discretion to administer. There must be clear guidance recorded within care plans for the management of PRN medicines and a requirement was issued. This has not been complied with and the requirement is repeated. The inspector was informed that only senior staff administer the medicines in the home. Staff training records show that staff expected to administer medicines have competed medication training. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. Activities are provided to people using the service and they are encouraged to remain in contact with their families and friends. Nutritious meals are provided in pleasing surroundings but the choice of meal should be made clear to people using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans show some individual routines of daily living. As part of the admission process, the home completes a section called ‘building a picture’ which is a life history of the individual which gives staff information about previous leisure pursuits, hobbies and other interests. During this inspection the registered manager said there is a list of weekly activities displayed on the notice board and this is used as a guide but people can choose what activities they would like to do on a daily basis. During lunch one person told the inspector they had taken part in an exercise group that morning. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 15 A small group of service users like to play cards regularly in the afternoons. One person spoken to said activities take place between 2:00pm and 3:00pm. At the previous inspection a requirement was issued for the social and recreational needs of people using the service to be met and these are must be recorded in the care plans. Initial information obtained about people’s social care needs and previous hobbies, work and leisure activities is recorded in care plans. There is an activities attendance sheet in each file examined which records the activities the individual has taken part in. These show that activities have included quizzes, cards and games and an exercise class. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. One person living n the home said the staff always make my relatives welcome when they visit and they are always offered a cup of tea and a biscuit. Family and friends are invited to participate in some of the social events organised. Service users are offered three meals a day. The menu is rotated on a four weekly cycle. The inspector had the opportunity to join service users for a lunchtime meal in the main dining room. The meal was relaxed, unrushed and well organised. People were well supported by staff and the food was attractively presented. There is a notice board which records the day’s menu. This does not advertise a choice of meal and this was referred to at the previous inspection. The inspector asked one person at lunch what they could have if they didn’t want the main choice of meal. They replied “we have to have what we’re given” and another person said “we don’t have a choice”. The inspector asked a staff member the same question, and she replied “we would arrange for something else to be cooked for that person”. The home should make it clear to people using the service exactly what the choices of meals are and this should be addressed. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience poor quality outcomes in this area. The home has a complaints procedure to ensure that people are able to raise their concerns and action taken to put things right. However the recording of complaints needs to be improved so that residents and families feel their views are listened to. Weaknesses detected in the registered providers lack of knowledge and awareness of recruitment practices has the potential of putting people at risk of harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure which is accessible to service users and their representatives. The Annual Quality Assurance Assessment informs us that the home has received three complaints since the last inspection and that none of these complaints were upheld. The complaints log in the home was examined. This was disorganised and it was difficult to fully assess the number of complaints received within the previous twelve months. Separate letters and pieces of paper were placed loosely in a file and for some of the complaints there was no evidence of the action taken and the outcome of the complaint which does provide evidence that all complaints have been fully investigated. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 17 A letter was seen in the manager’s office regarding a complaint/incident that occurred in the home but this complaint was not recorded in the complaints log. The Registered Manager said the owner was dealing with this complaint. A requirement is issued for improvement in this area. Procedures are in place for safeguarding vulnerable adults (SOVA) and staff have access to a whistle blowing policy. The home has a copy of the local authority SOVA policy. Training records demonstrate that staff have completed Safeguarding training and this is regularly updated. The Annual Quality Assurance Assessment tells us that there has been one safe guarding referral in the previous twelve months. Information has been given to the Care Quality Commission that the Registered Provider has introduced two potential care workers to the home, who have shadowed more experienced care staff and one of these has slept overnight in the home. The registered manager has confirmed that none of the necessary employment checks were undertaken for either of these staff. The Care Quality Commission were not informed about the first care worker to visit the home. When the second care worker was due to arrive at the home the Registered Manager informed the Care Quality Commission and the Registered Provider was contacted and informed that he must remove the second care worker from the home. The Registered Manager was advised to make made a safeguarding referral to the South Bucks Safeguarding Team regarding poor recruitment practices and this was complied with. Further serious shortfall shave been identified during this Key Inspection with regard to the recruitment procedures which has the potential to put service users at risk. This must be addressed ad a requirement has been issued. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. The standard of the environment within the home provides people who use the service with a homely place to live, however several improvements and upgrading of some areas of the home need to be completed to make the home safe for people who live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Chilworth House is a care home providing personal care and accommodation for 29 older people. 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 two lounges and a bright, spacious conservatory. These are well maintained and nicely decorated, bright and cheerful. There are personal touches around the home such as flowers, pictures, books and mirrors. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 19 Dining takes place in the conservatory and a further room attached to the main lounge. One double bedroom has now been changed into two single rooms. In one of these rooms the carpet has gathered up and presents a potential trip hazard to the occupant of the room. This must be addressed. In rooms 11 and 12 the service users complained that the windows are very drafty. In room 11 the window recently dropped and cannot now be opened safely. The window in room 12, when opened, presents a potential risk of dropping. Both windows must be made safe to open and shut and steps taken to eliminate drafts. A requirement is issued for these two areas to be addressed. There are accessible toilets available for residents, throughout the home and close to each lounge. All bedrooms seen are individualised and some contain their own items of furniture, personal possessions, leisure items including televisions, radios, and books. The inspector observed that hand washing facilities were available and also disinfectant hand rub was located throughout the home in order to promote safe practice in regard to infection control. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry floor finishes are impermeable and these and the wall finishes are readily cleanable. The Annual Quality Assurance Assessment tells us that all care staff have completed Infection Control training. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. The staffing numbers and staff training is sufficient and up to date to ensure that people who use the service benefit from staff who are who are competent to do their job. The management of the recruitment practices are unsafe which potentially puts service users at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty to ensure people’s needs are met. The Annual Quality Assurance Assessment tells us that out of seventeen permanent care staff employed to work in the home, nine have achieved a National Vocational Qualification level 2 or above. The Care Quality Commission has been provided with information that the Registered Provider has engaged staff to work in the home and one of whom slept overnight in the home for two nights, without them undergoing the proper checks as to their suitability for employment, thus putting residents at risk. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 21 The recruitment files for nine staff were examined during this inspection. These show that in four files there was no evidence of Criminal Records Bureau checks or POVA checks for the individuals. However the registered manager has since supplied three Criminal Records Bureau numbers for three of the staff identified. There are no dates supplied with this information. Two files showed that the individuals had commenced work before the home had received the individuals POVA first check or Criminal Records Bureau check. Two files contained only one reference and there were no up to date photographs of staff in any of the files examined. A requirement is repeated for improvement in this area. All staff complete an induction programme that covers the common induction standards for social care and this was seen in the files examined. During the initial induction to the home staff are extra to the numbers on the staff rota and work alongside more experienced staff. Training records show that staff are up to date with their mandatory training. There is specialist training available for staff, and an example of this is feeding and nutrition in the older person, communication skills and effective team building and care of ageing skin and prevention of pressure sores. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. There is a history of non compliance with requirements and evidence of poor procedures taking place which does not ensure the service users best interests and could compromise the health safety and welfare of those using the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager is Sue Ann Cook who has been in post for almost three years. She is registered with the Care Quality Commission and has completed the Registered Managers Award. Further training in the previous twelve months includes all mandatory training, and Dementia Awareness, Death, Dying and Bereavement. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 23 There are outstanding requirements which have not been met from the previous inspection. There remain considerable shortfalls in the service as highlighted in this report and a failure to meet requirements set at the previous inspection. There is a suggestion box in the home for staff and relatives to volunteer suggestions on how the service could be improved. The home aims to ensure that staff receive one to one supervision every six weeks and staff spoken to confirmed that they were receiving supervision. Copies of regulation 26 report visits were not available to look at for each month. These need to be undertaken on a monthly basis and must be available for inspection purposes and this will be a requirement of the report. Questionnaires have recently been sent out to service users but the registered manager said that the findings had not been collated into a report, which leaves the exercise open ended. Should a further exercise be carried out this year, it would be expected that the findings are collated and these are shared with the people who took part and relevant parties. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. The inspector did not sample any of the homes financial accounting processes and was advised by the registered manager that the home does not safekeep residents money. During one discussion with a service user, concerns were raised with the inspector about the level of the home fee’s and the service being provided. There is a health and safety policy in place and health and safety training is completed and up to date for all staff. Records were seen for fire safety. These cover the homes fire procedures, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually. The Annual Quality Assurance Assessment tells us that service reports are in place for Portable Appliance testing dated February 2009, gas appliances dated February 2009 and electrical installation dated January 2005. Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x 3 X x 3 Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(10) Requirement The registered person is required to ensure that the identified care needs of people using the service are detailed in the care plan. (Previous timescale of 30/07/2009 not met) The registered person is required to ensure that risk assessment documentation is reviewed and changes made as necessary to ensure staff are working to current information. (Previous timescale of 30/07/2008 not met) The registered person is required to ensure that clear guidance is recorded within care plans for the management of as required medicines.(Previous timescale of 28/02/09 not met) The home must ensure they fully investigate all complaints, and the nature of the complaint, the action taken and the outcome of the complaint is recorded and maintained in the home. The carpet in the identified bedroom must be made safe for the occupant and the windows in DS0000022964.V378536.R01.S.doc Timescale for action 30/01/10 2 OP8 13 (4) c 30/01/10 3 OP9 13(2) 30/01/10 4 OP16 22 30/12/09 5 OP19 23 30/01/10 Chilworth House Version 5.3 Page 26 6. OP29 17 bedrooms 11 and 12 must be made safe to open and shut and steps taken to eliminate drafts. The registered person must ensure that evidence of all recruitment checks for staff is available for inspection purposes. (Previous timescale of 28/02/09 not met) 06/12/09 7. OP33 26 The registered person is required 30/01/10 to ensure a monthly unannounced visit to the home is undertaken. This must include interviews with service users and their representatives, inspection of the premises and prepare a written report on the conduct of the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chilworth House DS0000022964.V378536.R01.S.doc Version 5.3 Page 27 Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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