Inspection on 18/07/07 for Chollacott House Nursing Home

This inspection was carried out on 18th July 2007.

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

Chollacott House Nursing Home 12/07/08

Chollacott House Nursing Home 14/02/07

Chollacott House Nursing Home 19/04/06

Chollacott House Nursing Home 31/01/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Chollacott House Nursing Home 61 Whitchurch Road Whitchurch Tavistock Devon PL19 9BD Lead Inspector Fiona Cartlidge Unannounced Inspection 18th July 2007 09:40 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 Chollacott House Nursing Home DS0000064645.V346480.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. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chollacott House Nursing Home Address 61 Whitchurch Road Whitchurch Tavistock Devon PL19 9BD 01822 612811 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) WWW.stone-haven.co.uk Stonehaven (Healthcare) Ltd Vacancy Care Home 27 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (3), Physical disability of places over 65 years of age (25) Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Two service users under the age of 65 in relation to the PD category only can be admitted Service users aged 65 years and over PD(E) Maximum registered 25 service users (both) LD Maximum registered 1 service user (both) OP Maximum registered 3 service users (both) A Registered Manager with the relevant experience, qualifications and skills to manage a Care Home providing Nursing is employed within 3 months of Stonehaven (Healthcare) Ltd being registered as the Provider for Chollacott House Sufficient numbers of staff with the skills and qualifications to meet the needs of service users are on duty at all times 14th February 2007 7. Date of last inspection Brief Description of the Service: Chollacott House is a large Edwardian building set in extensive grounds near to the market town of Tavistock. The home is registered to provide nursing care to a maximum of 27 Service Users over the age of 65, and 1 Service User with a learning disability. The accommodation is presented on two floors accessed via a passenger lift; there is level access throughout the building; there are 23 single rooms, 12 of which are en-suite and 2 double rooms 1 of which is en - suite. There is a large dining and lounge conservatory area leading on to a further smaller lounge, all on ground floor level. Information about the home was found in the entrance hall, people can request a copy of the latest inspection reports from the administration office. Information given to the Commission by the provider earlier this year indicates the current range of fees is from £381 to £585/week. Additional charges are made for chiropody, hairdressing, newspapers/magazines and activities. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 5 The home has been under the ownership of Stonehaven (Healthcare) Ltd since October 2005. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The site visit took place over 5 hours and 30 minutes it started at 09:40hrs and was unannounced. Two inspectors performed a partial tour of the home when some bedrooms and all communal areas were viewed. Three residents had their care case tracked this means their records were examined in detail and then 2 were spoken to in depth about the care and services they receive the other had their care observed. Five other residents were spoken with during the visit, as were the senior nurse on duty and 3 other members of the care team. Personnel records of 3 members of staff and policies and procedures were also inspected. What the service does well: People who use the service, spoke highly of the staff team saying how kind and attentive they where. One person using the service said that he wants his washing done separately and staff will do this for him. We observed some very good meaningful communication between the staff and residents. Prospective residents have a personalised needs assessment performed, this means that their needs are identified and planned for before they move to the home. People who use this service confirmed they receive a good level of care. All people who use this service are registered with a General Practitioner (GP). Records provided evidence that as well as visits from GPs, district and specialist nurses and chiropodists also visit. Records of outpatient appointments show that visits to community and hospital health resources are usually enabled. People are treated kindly and their right to privacy is upheld. A person using the service said: “All the staff have been very, very friendly. I’ve never heard them have a ‘cross’ word”. Staff were seen and heard knocking on doors before entering bedrooms. Staff observed in conversation with people using this service were heard to be courteous and respectful. People are encouraged and enabled to maintain contact with family, friends and representatives and the local community. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 7 Peoples rights to choice and control over their lives is respected and the food served in the home is liked and provides a balanced diet. Arrangements for protecting people who use this service and responding to their concerns are satisfactory. The majority of the environment is clean, warm, safe and comfortable. Not every bedroom was seen, but those that were looked homely and there was evidence that residents have been able to bring personal belongings with them. Those residents spoken to about their private accommodation said they like the décor in their own rooms and have what they need. Bedrooms had locks and lockable storage, providing people who use the service choice in relation to privacy dignity and security. The furniture, furnishings and equipment in communal rooms appeared to be in quite good order. What has improved since the last inspection? What they could do better: The manager of this home employed in December 2006, had left employment the week before our visit. The staff and people who use the service told us that they thought the manager had been good and had introduced many systems that had benefited people who work and live in the home. To ensure standards Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 8 are maintained the registered provider must as soon as possible employ a suitably qualified and experienced person to manage this service. In the interim a registered nurse must take the nursing/clinical lead at the home so that all nursing decisions are made by a person qualified, and with sufficient, knowledge to do so. To ensure people are not subjected to unlawful restraint, where equipment that is restraining in its nature is in use; this must be regularly reviewed by a multidisciplinary team, and the wishes of the resident must be respected unless they lack capacity to make a safe judgement. When an incident or accident occurs that affects the wellbeing of anyone living or working in the home, this should be analysed/investigated and action taken (if required) to prevent a reoccurrence. There were some gaps in medication administration records; this poses a risk to people because there is no evidence of whether or not the medication had been taken as it is prescribed. Some medication such as lotions and skin preparations had no record of administration. This also makes it difficult for staff to monitor the medications effectiveness. The process for medication administration was not safe. On two occasions during our visit we observed the medicines trolley being left unattended and although the trolley itself was locked there were medications left on the top of the trolley this poses a risk to people because people for whom the medication was not prescribed could take it and the person for whom it was prescribed may not receive it. The staff told us that there is currently no organised activities programme and therefore there were no records. To ensure that all people’s individual social and recreational needs are met information should be sought and recorded about their family and working history as well as their hobbies and interests. Programmes should be offered that take account of this information. 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. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 9 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 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 10 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): 3 (Standard 6 does not apply to Chollacott) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A personalised needs assessment means that people’s needs are identified and planned for before they move to the home. EVIDENCE: We looked at the personal records of three people who were using this service at the time of our site visit. One of these had recently been admitted from another part of the country and therefore a personal assessment had not been practicable. This person told us that they had provided information via the telephone about their needs. Staff from the home had contacted the Commission about this person’s admission and provided details about their needs. They confirmed that the admission would be safe. This person told us that the home was meeting and indeed exceeding their expectations. The other records we saw were of people admitted to the home over a year ago. They contained copies of assessments performed by health and social Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 11 care professionals and care plans provided by the commissioners of their care. They provided sufficient information from which care could be planned. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most people who use this service can be sure their health and personal care needs will be met. The system for administering medication is not completely safe. This poses a risk to people who use this service. People are treated kindly and their right to privacy is upheld. EVIDENCE: People who use this service confirmed they receive a good level of care. Personal records held on behalf of 3 were examined in detail; there were documented assessments, which provided information about skin conditions, moving and handling, safety - including risk of falls and nutritional needs. The information in the assessments had been used to form the plans of care and provided the basis from which the care was to be delivered. A person using the service, newly admitted to the home, confirmed that they had been involved in producing the plan. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 13 One resident, with a long history of falls from his bed, had bedrails in use. Records showed these had been advocated by a general practitioner because of the number of falls this person had suffered over a number of months. However, records showed the person had continued to fall from the bed at night, despite the bedrails. The person themselves described to us: ‘crawling to the bottom of the bed to get out, and it taking up to an hour to do so’. They also confirmed that the bedrails were being used against their wishes, and the recommendation made in October 2006 by other health care professionals. Records also showed this person regularly falls at the same time, early in the morning, but this had not been investigated. We found that the person’s blood pressure was recorded, but this was following falls, not as part of investigating why the falls occurred. A recommendation to place an alarm, to alert staff if the person tried to leave the room via the French doors leading into the garden, had not been actioned. Another resident whose records we studied showed they had sustained an injury to their head resulting in bruising to their forehead and an eye. Staff told us they assumed the injury had occurred whilst the person was being mechanically moved with a hoist. There was no evidence that this had been properly investigated and therefore no action taken to minimise the risk of such an injury occurring again. Records are written about all visits to the home by social or health care professionals, and all service users are registered with a General Practitioner. Records provided evidence that GPs, district and specialist nurses and chiropodists visit. One person, with a history of falls, had been referred to physiotherapy. Records of outpatient appointments show that visits to community and hospital health resources are usually enabled. Where people need an escort the family, or persons representatives, are asked to provide this. Otherwise a charge is made for the additional staffing. We examined the system in place for the homes management of people’s medication. The storage facilities were satisfactory. There were some gaps in administration records. This poses a risk to people because there is no evidence of whether or not the medication has been taken as it is prescribed. Some medication, such as lotions and skin preparations, had no record of administration. This also makes it difficult for staff to monitor the medications effectiveness. The process for medication administration was not safe. On two occasions during our visit we observed the medicines trolley being left unattended. Although the trolley itself was locked there were medications left on the top of it. This poses a risk to people who might be confused. Staff were seen and heard knocking on doors before entering bedrooms and were carrying out personal care for service users in private. Staff observed in conversation with people were heard to be courteous and respectful. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 14 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 15 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 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced in the home meets the expectations of most people who use this service. People are encouraged and enabled to maintain contact with family, friends and representatives and the local community. Peoples rights to choice and control over their lives is, for the most part, respected and the food served in the home is liked and provides a balanced diet. EVIDENCE: Records held about service users included only limited information about their social and economic histories. A more person centred approach to care allows the staff to know more about the people they care for such as their family and working history as well as their hobbies and interests. Two, fairly able, people who use the services told us they were satisfied with their daily life at the home, one adding: “I like to read and chat. I don’t want activities”. A visitor said that six months ago there used to be outings, but he believed they had stopped. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 16 The feedback about food was very positive. All of the people spoken with said how good it was. The food served at lunchtime looked and smelt appealing. People requiring assistance with their meals were mostly given this in an appropriate manner. One person we spoke with said the kitchen staff had told them what the main meal at lunchtime was to be (savoury mince) but because they did not like this they had been able to choose a satisfactory option. We were told that on the day of our visit a choice of menu had not been advertised in writing because the main cook was not on duty. We were told that people had been asked verbally if they were happy to have the main dish of the day. The people living in the home said they were happy with the visiting arrangements. Visits were seen to take place socially in the lounge and privately in residents own accommodation. Visitors told us they feel welcomed into the home. People we spoke to, including members of staff and people who use the service, told us people using the service are able to decide how and where they spend their time. This includes the times they rise and retire. Chollacott House Nursing Home DS0000064645.V346480.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are protected by staff that are responsive to complaints and who understand how to protect vulnerable adults in their care. EVIDENCE: This service has a complaints procedure. It is clearly written and easy to understand. It was seen displayed in the hallway. People who use the service confirmed that they felt comfortable discussing issues with the staff. The record of complaints confirmed that people felt able to take complaints to the (previous) manager. They had been investigated and the outcome recorded. There have been no complaints referred to the Commission about this service since its last inspection. Records seen show that the Staff have been made aware of, and attend training on, the recognition and reporting of incidents or allegations of abuse or neglect. The homes policy and procedures for safeguarding adults gives clear specific guidance. Staff spoken to told us what they would do if they suspected abuse or neglect was occurring. People who use the service told us they feel safe living in the home. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 18 Chollacott House Nursing Home DS0000064645.V346480.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design of the home is adequately maintained, comfortable and meets the needs of people using the service. Attention to cleanliness and safety is not sufficient. EVIDENCE: A recently admitted person said his accommodation was adequate, his bed was comfortable, but he would have preferred a shower available in the room. A partial tour of the home took place. Not every bedroom was seen, but those that were looked homely and there was evidence that residents have been able to bring personal belongings with them in to the home. Those residents spoken to about their private accommodation said they like the décor in their own Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 20 rooms and have what they need. The bedrooms all had locks and lockable storage providing people who use the service choice in relation to privacy dignity and security. The furniture, furnishings and equipment in communal rooms appeared to be in good order. These rooms are clean, pleasant and fresh. On the day of the visit the conservatory lounge and dining room were very warm despite the windows being open and fans in use. Air conditioning may need to be considered to provide a comfortable temperature throughout the year. Some more able people who use the service were seen using the level pathways in the garden. We found debris on the first floor corridor. This appeared to have been left following maintenance to the ceiling, other parts of which remained in a poor state of repair. A Passenger lift provides access to less mobile residents between floors. We found an unlocked cupboard on the ground floor containing cleaning products. Beside this there was a document about the safe control of substances that may be hazardous to health, cleaning products. People who use the service should be protected from any chemicals, which might be a danger to them if handled inappropriately. We visited the kitchen, looked at a previous environmental health inspection record and spoke with the cook. We found the microwave, cooker, toaster and some shelves were insufficiently clean. The cook was unaware of any kitchen schedule for deep cleaning, despite West Devon Borough Council (environmental health) having recommended this in November 2006. She showed the food storage room, which was spotlessly clean and tidy, confirming that she had been trying to work her way through all that needed cleaning, but that no time seemed to be allotted for it. We also found that, although the record of fridge and food temperatures were being taken, no record of them was kept. And, two fridges were sharing one thermometer. We feel that the home had not met the expectations of West Devon Borough Council (environmental health) and will inform them of this. At the time of the site visit we found the laundry to be clean and tidy. The rest of the environment was found to be largely odour free and hand wash facilities and disposable gloves were generally available through out the home, which should protect people from cross infection. Staff confirmed they received fire safety training, the home has a fire risk assessment and the fire systems were regularly serviced. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 21 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are well trained and supported, and employed in sufficient numbers to meet current residents needs. EVIDENCE: People who use the service spoke highly of the staff team saying how kind and attentive they where. One said: “When I use the call bell they’re here within minutes”. We observed some very good meaningful communication between the staff and residents. Three Personnel files were examined, these records showed a commitment to safe recruitment practises. Files contained detailed application forms, 2 written references. There was evidence of Criminal Record Bureaux checks, and each file held proof of the person’s identity. All of the files contained copies of terms and conditions of employment. Training and development records provided evidence that training is provided and ongoing. Recent training included: • End of life care • Taking blood samples • Moving and handling & Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 23 • Continence and catheterisation All staff spoken to confirmed they receive sufficient training to enable them to meet the needs of those living in the home. Members of staff who have worked at the home for a number of years told us that recently the training programme has improved. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 24 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Management arrangements have met the needs of the service, and the quality of the service has continued to improve. EVIDENCE: The manager of this home, employed in December 2006, had left employment the week before our visit. An application to register, as manager under the Care standards Act 2000, had not been received by the Commission. The staff and people who use the service told us that they thought the manager had been good and had introduced many systems that had benefited people who work and live in the home. These included increasing staff Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 25 numbers, good provision of equipment and introducing a training programme that had improved the skills of individuals as well as the team. A new member of staff said how happy she was at the home. We saw that staff recruitment processes have also improved since our last inspection. We observed good moral among the staff team. We were told that sickness levels among the staff had dropped over the preceding months; this had meant staff were less tired from working long hours covering other peoples duties. Staff said continuity of care had improved. One member of staff we spoke to said: “He (the recent manager) was brill’. If we needed any thing, like equipment, he’d get it for us”. We were told that a deputy manager had been appointed since our last inspection, and again people spoke highly of her organisational skills, particularly in relation to administrative duties. This we were told allows the care team more time to meet the needs of people who use the service. However, she is not a registered nurse with the appropriate qualifications, skills and experience to take decisions regarding admission and health care of people using the service. This might lead to people being admitted whose needs can not be best met at the home and puts the welfare of existing people at risk. We found that regular formal communication systems were in place. Regular monthly staff meetings had been held and minutes of these were available. Staff who spoke to us said communication within the home was much improved. During this inspection examination was made of the arrangements for dealing with money held in the home on behalf of people using the service. The home has a robust system, which ensures that service users’ monies are safeguarded and protected. Purchases are receipted, and examination of the system demonstrated that references could be cross-referenced with purchased items. The actual balances of 2 people’s monies were checked against records and found to be accurate. Health and safety were generally satisfactory although: • The cause of accidents and incidents are not always fully investigated. • Cleaning chemicals were not locked securely and could pose a risk to confused residents. This has been a previous concern, which has not been addressed. • There is no cleaning schedule for the kitchen and insufficient time to deep clean. • Food and fridge temperatures are not routinely recorded to ensure storage and cooking temperatures will protect people from the possibility of contaminated food. Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 26 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 27 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 3 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 28 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 12(3) Requirement Timescale for action 31/08/07 2. OP7 13(4) 3. OP9 13(2) People should be involved in the review of their plans of care, their wishes must be respected unless they lack capacity to make judgements and then a multidisciplinary approach should be taken. This relates to the use of bedsides, which were not wanted by the person and not effective. The cause of falls must be fully 31/08/07 investigated. Steps agreed to remove or reduce the risk must be carried out. This relates to the ‘pressure mat’, which was not used despite it being planned as a method to reduce the falls. These steps will reduce the likelihood of injury. 18/08/07 The registered person must ensure the health and well being of service users through the correct recording and administration of medication in the care home. This relates to: Gaps in administration records, which poses a risk because there Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 29 is no evidence of whether or not the medication has been taken as it is prescribed. Some medication such as lotions and skin preparations had no record of administration. This also makes it difficult for staff to monitor the medications effectiveness. The medicines trolley being left unattended and although the trolley itself was locked there were medications left on the top of the trolley this poses a risk to people because people for whom the medication was not prescribed could take it and the person for whom it was prescribed may not receive it. All substances that could be hazardous to health (cleaning materials) must be stored securely when not in use. Carried forward from 01/09/06 and 01/04/07 This relates to a cupboard on the ground floor containing cleaning products found unlocked. In order that correct levels of food hygiene are maintained and to prevent food contamination, the Kitchen must be clean and hygienic at all times. In order to ensure food is kept and cooked safely a daily record of fridge temperatures and cooking temperatures must be recorded. 4. OP38 13(4) 01/08/07 5. OP38 16(2)(j) 18/08/07 6. OP38 16(2)(j) 01/08/07 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 30 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 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Chollacott House Nursing Home DS0000064645.V346480.R01.S.doc Version 5.2 Page 32 - 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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