Inspection on 20/01/09 for Chilworth House

This inspection was carried out on 20th January 2009.

CSCI found this care home to be providing an Adequate service.

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 20/05/08

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Chilworth House 7 Rectory Avenue High Wycombe Buckinghamshire HP13 6HN Lead Inspector Barbara Mulligan Unannounced Inspection 20th January 2009 10:30 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.V373903.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chilworth House DS0000022964.V373903.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 simon.chilworth21googlemail.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.V373903.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 May 2008 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. The fees for the home range from £450.00 for a shared room to £650.00 for a single room. Chilworth House DS0000022964.V373903.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 this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. The inspection officer was Barbara Mulligan. The registered manager is Sue Ann Cook. The inspection consisted of discussion with the registered manager and other staff, opportunities to meet with some people who use the service, examination of some of the home’s 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. Twenty-eight of the National Minimum Standards for Older people were assessed during this visit. Six were assessed as almost met, standard three was assessed as standard exceeded and standard 6 was assessed as not applicable and the remaining standards were fully met. As a result of the inspection the home has received eight requirements. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation 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 that consists of care staff 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 own rooms with their own furniture and personal belongings. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 6 The provision of meals is good and much appreciated by the residents spoken to. Training for care staff is good and people who use the service benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking National Vocational Qualifications training. There is a good range of policies and procedures, providing staff with relevant information about all aspects of care and the home/organisation. The evidence seen and comments received indicate that this service meets the diverse, racial, cultural, disability of individuals within the limits of its Statement of Purpose. What has improved since the last inspection? The Statement of Purpose and Service Users Guide has been reviewed and changes made as necessary. Some areas of the care planning documentation have been enhanced and improvements continue to be made. The manager has sent questionnaires out to people who use the service about the types of activities they would like to see provided in the home. Following the results of this exercise the registered manager will implement a time-table of activities. The home has a copy of the Basic Food Hygiene certificate for the weekend chef. The home has completed a review of their policy and procedures about safeguarding vulnerable adults, to reflect the local authorities multi agency policies and procedures. The home started to improve its quality assurance and quality monitoring systems, based on seeking the views of service users. Two types of service satisfaction questionnaires have been sent out to people who use the service. These have been for activities and personal care. The registered manager has also sent out questionnaires to relatives and people who use the service following three main events held in the home. The induction programme has been updated and all care staff in the home are in the process of completing this as a refresher. The care staff have received up to date mandatory health and safety training and training records demonstrate that planning has already been undertaken for future training. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the previous inspection it was identified that the home’s Statement of Purpose and Service User Guide needed to be updated and copies made available to prospective individuals and people living in the home. A requirement was issued for this to be completed. The inspector was given a copy of the combined document which contains all the necessary information as detailed in the care homes regulations. The contact details for the Commission for Social Care Inspection need to be updated with the Maidstone address. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 10 During this visit the inspector examined four files including those new to the service. Each file had a completed needs assessment and each one contained further information about the person’s life history, family and friends, likes, dislikes and preferences. The assessment tool covers medicines, diet and feeding needs, health and hygiene, mobility, continence, eyes, teeth, washing, bathing, tissue viability, allergies and communication. Alongside this the home has recently introduced 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. There is a further pre-admission information sheet which covers likes and dislikes, interests and hobbies, pastimes, history of falls, religion, any particular worries, times preferred for bathing, going to bed, early morning calls and if they would like to use visiting the hairdresser, whether they prefer company at meal times and whether they want newspapers and any alcohol. The home also completes a family tree as part of the pre-admission process. Altogether this is a comprehensive process and is to be commended. It is noted that the service users have been asked their preferred name which is indicated throughout any further documentation seen, this is noted as good practice. 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.V373903.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. 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. People who use the service feel that they are treated with respect and dignity and that their right to privacy is upheld ensuring personal care is delivered appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four service users was case tracked and their care plans examined, including those new to the service. Following the previous inspection a requirement was issued for all aspects of the health, personal and social care needs of people who use the service are documented in the care plans. As identified at the previous inspection the care plans examined cover just three main areas. These are mobility, personal hygiene and nutrition. Although Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 12 these 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. Not all the care needs identified in the initial needs assessment have a plan of care in place, which could result in the peoples needs not being met. For example, one assessment states that the individual suffers from depression. However there are no guidelines for staff to follow about how to support the individual with their depression. None of the care plans examined contain information about people’s oral health care needs. Another needs assessment identifies that the individual wears “two hearing aids, but not very often”. Again these are not mentioned in the care plan and there is no instruction for staff on how to support the individual with these. This has resulted in the service user not wearing the hearing aids at all. A requirement is issued for improvement in this area. In one file looked at for an individual new to the home they have been assessed as diabetic. However the nutritional section for this person was not completed. The registered manager said she thought that this had been removed by staff and not replaced. There was no record that this person has been weighed since she was admitted to the home. A requirement is issued for nutritional screening to be recorded in this care plan. The same file contains no information about this persons social care needs/activities. It does state that she “enjoys company” but there is no further information. Many entries in the care plans and assessments are too vague and require further detail. For example, in one moving and handling assessment under bathing it records, “usual bathing procedure” and the care plan for the same person records “ would like a bath every Tuesday morning”. These statements should be more detailed to provide specific guidance for staff to follow and is strongly recommended. Risk assessment documentation was looked at in the care plans. In each file there is a moving and handling assessment, a falls assessment, a Waterlow pressure area care assessment, a bath risk assessment and a nutritional assessment. In one moving and handling assessment it records that the individual has “a tear in the skin on her leg, causing infection and weeping”. The inspector was unable to find any information in the care plan about this. When queried with the registered manager she said that this has now healed. Although the assessment has been reviewed monthly, the information recorded in the moving and handling assessment must be updated to ensure staff are working to current information and this will be a requirement of the report. Additional support is accessed through the local GP surgeries, where people who use the service can access physiotherapists, occupational therapists and speech therapists. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 13 The home receives district nurse support and they are available for advice regarding pressure area care and can assist in the provision of pressure relieving equipment. Staff provide support to individuals needing to attend outpatient and other appointments. There is a sheet in each file to record visits to health care professionals such as dentist, optician and the GP. In all files examined this sheet was empty and the registered manager said that she has only just implemented these. It is strongly recommended that these are completed in all cases. 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. In general the medication protocols are well managed, organised and safely stored. There were no controlled medications being used at the time of the visit. The procedures for the administration of medicines were examined during this inspection. We looked at medicine records, storage and policies and procedures. From the records and medicine supplies it is evident that on the whole people get their medicines as prescribed by their doctors. However, the Medication Administration Records (MAR) were looked at and there were numerous omissions found. A requirement is issued for improvement in this area. There are 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 this will be a requirement of the report. Medicines were stored securely for the protection of people who use the service. The registered manager advised that only senior staff are trained to administer medicines. Training records for these individuals show that they have completed recent medication training. During this visit staff were observed to address residents in a professional and caring manner and residents were addressed by their first or full name and where appropriate. Staff were observed to preserve and maintain residents dignity and privacy by knocking on their room doors prior to entry and supporting resident’s discreetly to the bathroom. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. The routines of the home are flexible and residents have a choice as to how they spend their day, however individuals are not presented with adequate opportunities for social and recreational inclusion, which could leave them at risk of becoming socially isolated. The meals are of a good standard and meet resident’s nutritional and social needs, however residents need to be made aware of the alternative selection of meal to allow them to make a preferred choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was identified at the previous inspection that the home was failing to meet the social and recreational interests of people who use the service. This was particularly relevant to people who are more dependant on staff for their care needs. A requirement was issued for improvement in this area. 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 Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 15 residents can choose what activities they would like to do on a daily basis. On the afternoon of the visit the inspector observed a small group playing cards and a larger group taking part in a colouring group. Initial information obtained about people’s social care needs and previous hobbies, work and leisure activities is good. However this is not carried through to the care plans seen. Although there are activities available in the home it is uncertain if these are meeting the social care needs of people using the service. One person spoken to on the day of the visit said, “I get very lonely. I like to stay in my room but it’s off the beaten track and sometimes I don’t see anyone for hours”. Care staff undertake the activities for service users in the afternoon. During a discussion with several people using the service the inspector was told that “staff usually provide some form of activity but this is often cut short as the carer is needed elsewhere. Activities are not a priority here. It’s not their fault, they are very busy”. The registered manager said that she has recently sent out questionnaires to people who use the service about the type of activities they would like to see provided. The registered manager said she has only recently received these back and will use these to facilitate a new programme of activities. The requirement issued at the previous inspection for “the social and recreational needs of people using the service are met and these are recorded in the care plans” will be repeated. Several people spoken to on the day of the visit said that they have taken part in a Christmas party, a Sunday afternoon tea and a Summer Garden Party. Families and friends were invited to these events and there are numerous thank-you cards and compliments about these activities. The management ensured that the home keeps in contact with the local community and said that “there is a church service on the second Sunday of very month and this is open to families as well. A minister visits the home to talk to people individually on a monthly basis”. There is a visiting hairdressing service who was at the home for most of the day during the inspection and she visits the home weekly. There are various visiting entertainers who visit the home and the local school visits several times a year. Residents spoken to said that family and friends can visit when they wish. One individual said, “my family visit me twice a week and the staff are very good. They always offer them drinks and lovely cakes or biscuits”. Another person said that “my daughter visits me most days and she is always made to feel welcome.” Service users are offered three meals a day and the menu is rotated on a four weekly cycle. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 16 The inspector had the opportunity to observe the lunchtime meal. This was relaxed, unrushed and well organised. The main meal was chicken casserole which was attractively presented and tasty. When staff presented each person with the meal they did not inform the individual what the meal was. There did not appear to be an alternative available. There was no menu displayed to remind people what was available for lunch. There is a large white board in the dining area which the registered manager said the daily menu is usually written on. This was not the case on the day of the visit. It is strongly recommended that the daily menu is clearly displayed and shows the alternative meal available for that day. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The complaints and safeguarding policies and procedures work well and residents and families feel their views are listened to. This judgement has been made using available 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 four complaints since the last inspection. These have been recorded and dealt with, within the stated timescales. There is a suggestion box in the main hallway and a copy of the homes complaints procedure is contained within the Service Users Guide and Statement of Purpose. The Commission for Social Care Inspection has not received any complaints about this service since the pervious inspection. Most residents and their families who returned the questionnaires said that they knew who to complain to. Following the two previous inspections it was identified that the homes policy statement regarding reporting abuse was noted to be in conflict with the local authorities multi agency procedures. For example, staff are advised to report sexual abuse to social services but report all other abuse to the proprietor or ‘care manager’ (manager of the home). An immediate requirement was issued Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 18 at the first inspection for the home to review their policy and procedures regarding safeguarding vulnerable adults, to reflect compliance with the local authorities multi agency policies and procedures in order to safeguard people in their care. This had not been complied with at the previous inspection and a repeat requirement was issued. It is pleasing to see that this was updated in July 2008, and reflects the local authority safeguarding procedure. There is a whistle blowing procedure in place which has recently been updated. There have been no safeguarding referrals since the previous inspection. Staff training records show that twenty two care staff have completed safeguarding training in the last two years and five staff need to complete this. The home has a copy of the local authorities multi agency procedures for safeguarding adults dated 2004. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. Quality in this outcome area is good. The environment is clean and homely and provides a comfortable place for residents to live. This judgement has been made using available 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. Dining takes place in the conservatory and a further room attached to the main lounge. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 20 There are 26 single bedrooms and two double rooms. The inspector was invited to look at several personal bedrooms. 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. There is a system in place to address day-to-day maintenance issues, so that the safety of service users and staff is safeguarded. 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.V373903.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. People who use the service benefit from a staff team who are adequately trained and sufficient in numbers to support the residents with personal care. The home has a recruitment procedure that needs to be strengthened to ensure the safety and protection of residents in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the personal and healthcare needs of residents are met. However, feedback from people who use the service and a lack of information present in care plans does not fully demonstrate that the home is not fully meeting the social and recreational needs of people who use the service. The home would benefit from an activities coordinator who will not be used as a carer when the staff team is short of staff. People who responded to the CSCI surveys said there had been an improvement in the staffing and the staff seem to be more regular now which is nicer for the people living in the home and you dont have to worry so much because you know the staff know your relative and mum is much happier now, she knows all the staff and they know her. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 22 The registered manager explained that the home employs a multi-cultural workforce and equality and diversity issues are addressed both by people living in the home and staff. The home continues to support staff on NVQ training and the Annual Quality Assurance Assessment tells us that there are twelve staff who have achieved NVQ level 2 training or above. During the previous inspection it was identified that improvements needed to be made to the staff recruitment files. For example, one file contained only one written reference, another file showed that the Criminal Bureau Records check application form had been returned due to errors but there was no evidence of a returned copy. One file looked at did not have the interview questions sheet completed and in another file the medical questionnaire was not completed. In some files there was evidence of training and development certificates and in others there were none available. Only two files had evidence of an induction. A requirement was issued for improvement in this area. The inspector examined four staff files including those new to the service. The staff file for the person newest to the service did not contain any references and the application form does not provide any addresses for contact with the referees. The registered manager said that she thought these were with the registered provider at the organisations main office. These must be available for inspection purposes and this will be a requirement of the report. The registered manager said that the home has introduced the Common Induction Standards Workbook. Induction training is presently being provided for all staff as an update or refresher. This has been taking place over the previous three months and was taking place on the day of the inspection. There is evidence of this in staff training files. Six staff training files were examined and these show that mandatory training has been completed for most staff. The home has employed the services of two consultants who are providing staff with necessary training and providing the registered manager with support and advice as needed. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The home provides a consistent service to people using the service and there are systems in place to protect the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for approximately two years. She has now registered with the Commission for Social Care Inspection. She is currently undertaking the Registered Managers Award. Further training in the previous twelve months includes all mandatory training, communication and Deprivation of Liberties training. The home has employed the service of two consultants who provide training for staff and are available to provide advice and support to the registered Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 24 manager. Progress has been made since the previous inspection and needs to continue. The inspector asked the registered manager about the homes Quality Assurance systems in place. She said that she has sent out questionnaires to people who use the service about activities and personal and healthcare needs. There is little evidence of any further Quality Assurance Systems in place and the Annual Quality Assurance Assessment states that the home intends to improve the Quality Assurance process in the next twelve months and this is recommended. 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. Records were seen for fire safety. The registered manager said that the person nominated to carry out the testing of the home fire alarm has not been done so appropriately and the manager has asked a fire safety company to visit the home to service all fire safety equipment. The local fire authority last visited the home in February 2008 and the home was required to install door guards on six doors. This has been completed for three doors and the remaining three are due to be completed in the following month. All staff have completed recent fire safety training. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. The Annual Quality Assurance Assessment (AQAA) states that the home has gas appliances but does not inform us when it was last serviced and the inspector was unable to find the service certificate at the home during the visit. This must be completed annually and made available for inspection purposes. A requirement is issued for improvement in this area. There was a service certificate for PAT testing dated February 2008 and the AQAA states was undertaken in January 2005. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 25 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 4 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 X X 2 Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 26 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. 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. The registered person is required to ensure that a full nutritional plan of care is recorded in the identified care plan as detailed in the report. The registered person is required to ensure the social and recreational needs of people using the service are met and these are recorded in the care plans. (Previous timescale of 30/07/08 not met) The registered person is required to ensure that staff sign the medicine administration record (MAR) when they have administered medicines. The registered person is required DS0000022964.V373903.R01.S.doc Timescale for action 30/07/09 2. OP7 15 (10) 30/07/09 3. OP8 12 07/02/09 4. OP12 16 (2) (m) (n) 30/04/09 5 OP9 13(2) 05/03/09 6. OP9 13(2) 28/02/09 Page 27 Chilworth House Version 5.2 7. OP29 17(1) 8. OP38 23(2) to ensure that clear guidance is recorded within care plans for the management of “as required” medicines. The registered person must 28/02/09 ensure that evidence of all recruitment checks for staff is available for inspection purposes. The registered person is required 30/03/09 to ensure that gas appliances are serviced annually and made available for inspection purposes. The registered person is required to provide the Commission with the most recent service certificate. 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 It is recommended that the care plans contain more detailed and specific guidance for staff to follow, to ensure they can fully meet the needs of the people using the service. It is strongly recommended that all visits to health care professionals are recorded in all cases. It is strongly recommended that the daily menu is displayed in the home and shows the alternative available meal for that day. It is recommended that the home improves and strengthens the Quality Assurance systems within the home. 2. 3. 4 OP8 OP15 OP33 Chilworth House DS0000022964.V373903.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V373903.R01.S.doc Version 5.2 Page 29 - 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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