Inspection on 31/01/06 for Chollacott House Nursing Home

This inspection was carried out on 31st January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Chollacott House Nursing Home 12/07/08

Chollacott House Nursing Home 18/07/07

Chollacott House Nursing Home 14/02/07

Chollacott House Nursing Home 19/04/06

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 61 Whitchurch Road Whitchurch Tavistock Devon PL19 9BD Lead Inspector Fiona Cartlidge Announced Inspection 31st January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 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 DS0000064645.V268026.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chollacott House Address 61 Whitchurch Road Whitchurch Tavistock Devon PL19 9BD 01364 644208 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) Stonehaven (Healthcare) Ltd Vacancy Care Home 25 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 DS0000064645.V268026.R01.S.doc Version 5.1 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 20/07/05 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, personal care only to a maximum of 3 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. The home has been under the ownership of Stonehaven (Healthcare) Ltd since October 2005. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 and three-quarter hours and was announced. The lead inspector Fiona Cartlidge was joined by an inspector colleague Helen Tworkowski between 1.00pm and 5.45pm. Information was received from the registered provider before the inspection as was written feedback from 4 residents and 3 visitors/relatives. A tour of the home took place and personal records of 3 residents and 3 staff were inspected. The inspector spoke to 4 members of staff on duty and 15 of the residents, 5 visitors and the Manager. It was disappointing that despite the inspection being announced 6 weeks before the date it was carried out, there was no representation from the registered provider. What the service does well: All of those spoken to during the inspection were extremely complimentary about the staff saying they are kind, hard working and thorough. Quotes included’ the staff are wonderful, kind and caring’ ‘ the staff are marvellous and friendly we have lots of laughs’. The inspector observed that the interaction between the staff and service users was extremely good, each individual being treated with respect in a supportive manner. The environment is homely; the décor and furnishings in bedrooms are based on the individual choice of those living with in them. A full and detailed assessment is performed on prospective residents prior to their admission and this information is seen by staff at Chollacott to enable them to make a decision about if/how the individuals needs can/will be met. The homes medication system is well-organised and easily audited and administered from purpose built trolleys directly to the residents on a 1:1 basis. The inspector read some letters that had been sent to the manager and staff , thanking them for the care provided specifically for their ’support, kindness and understanding’, ‘for their loving and professional care’ one indicated that they felt ‘privileged to have experienced such a compassionate environment’ another described ‘a warm, caring and happy environment saying their relative had been treated with dignity, care and affection’. Visitors feel welcomed into the home at any time and are able to visit their relative/friends in private. The manager of the home is professional and approachable. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 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 Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 The admission process is safe. Some information provided in the statement of purpose and Service users guide is misleading. The contract/terms and conditions of residency lacks some details. EVIDENCE: The inspector was provided with copies of the homes statement of purpose and Service users guide to look at during the inspection. The service users guide states that the home provides a range of meals, residents can chose from; this was not found to be the case for the lunch time meal where there is no choice of meal offered/advertised the document also states that the home will continually offer a wide range of social and leisure activities this was not found to be evident in practise. The Complaints procedure included in the guide did not ensure that residents and or their representatives are given information about complaining to the Commission for Social Care Inspection (CSCI) at any time, it indicates the CSCI should only be contacted if peoples complaints have not been dealt with appropriately by the manager or registered provider of the home. The statement of purpose provided a lot of information about how Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 10 people suffering with dementia would be cared for this is misleading because Chollacott is not registered to provide care to people who suffer with dementia. The inspector examined the personal records held within the home on behalf of 3 of the residents one of these contained a copy of the contract/terms of residency provided by Stonehaven (Healthcare) Ltd. The document did not contain specific information about the personal accommodation provided for the resident i.e. type of room single or double and specific identity of room i.e. its number/location. The document also contained information on how to make a complaint but it did not make a clear statement that complaints about the home can be made to the Commission for Social Care Inspection (CSCI) at any time/stage. All three records contained evidence that a full and detailed assessment had been performed on the resident prior to their admission and that this information was seen by staff at Chollacott to enable them to make a decision about if/how individuals needs can/will be met. One of the records of a recently admitted resident provided evidence that the matron/manager had visited the prospective resident in the local hospital to perform a needs assessment before there admission to Chollacott had been agreed. Residents told the inspector that they or their relatives had visited the home to view it and meet other residents and the staff before any decision about their admission had been made. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Most health care needs of residents are regularly reviewed and action is taken to meet those needs. When resident’s weights are not regularly recorded and there are no formal processes in place for nutritional screening there is a risk that this may impact on their physical well being. The homes medication system is well managed and safe. Service users privacy is not always upheld. People who are dying and their relatives are well supported. EVIDENCE: Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 12 The sample of plans of care that the inspector examined contained basic detail of the action which care staff need to take to meet residents needs associated with activities of daily living, there was evidence that Staff in the home on an at least monthly basis had reviewed the plans; There was no documentary evidence of residents and or their representatives involvement in the care planning process. Examination of 10 of personal records and discussion with residents confirmed that care staff maintain the personal and oral health of each resident and wherever possible, support the service users capacity for self care. Written feedback from 4 residents indicates that they all feel well cared for. Registered nurses have performed assessments to identify risks of pressure ulcers, moving and handling, and continence; aids and equipment are provided where necessary. There was no evidence of nutritional assessments or screening. All service users are registered with a GP. Records of appointments and visits provided evidence that the manager enables residents to have access to specialist medical, nursing and therapeutic services and care from hospitals and community health services according to need. During a tour of the home to visit and speak with residents, the inspector noted that most staff do routinely knock on the doors to residents private accommodation before entering; there was one occasion however when the inspector was seeing a resident in their own accommodation with the door closed when a qualified member of staff entered without knocking or obtaining permission to enter. The written feedback from 4 residents indicates that they all feel their privacy is respected. Registered nurses manage the medication system; the inspector looked at storage and recording – controlled drug stock was checked against records and found to be correct. The homes medication system is well-organised and easily audited and administered from purpose built trolleys directly to the residents on a 1:1 basis. Disposal of unused medication is safe, well recorded and removed by a licensed contractor. The inspector read some letters that had been sent to the manager and staff from relatives of residents who had died in the home, thanking them for the care provided specifically for their ’support, kindness and understanding’, ‘for their loving and professional care’ one indicated that they felt ‘privileged to have experienced such a compassionate environment’ another described ‘a warm, caring and happy environment saying their relative had been treated with dignity, care and affection’. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The lifestyle in the home does not satisfy the social and recreational needs of all residents. Residents are able to maintain contact with family and friends. Resident’s choices are not always upheld. Not all residents receive what they consider to be a wholesome and appealing diet. EVIDENCE: The commission received written feedback from 4 residents about social activities available in the home 1 indicated they do not feel suitable activities are provided the other 3 indicate that social activities are sometimes suitable. One resident told the inspector they felt they were simply existing not living and gave an example that they had only had one trip away from the home in 2 years. Arranged social activities were seen to be advertised on a notice board in the ground floor corridor and included for January - bingo, musical entertainment and provision of holy communion. On the day of inspection a volunteer dog and her owner were visiting the residents which they obviously enjoyed and at the same time a person employed through an activities agency was also visiting with her dog and chatting to residents. The same 4 residents provided written feedback about the food served in the home 2 said they liked the food, 1 said they sometimes like the food and the other said they did not like the food. Residents and visitors told the inspector Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 14 that since the home had changed ownership the food had changed they were aware that they now received a lot of frozen produce unlike before when most meat and vegetables were fresh. One person who came from a farming back ground and had always been used to fresh vegetables said the frozen vegetables did not taste good. The inspector was told the only fresh produce bought in now is potatoes and onions. The complaints folder held one complaint about the poor quality of meat served for a meal earlier in the month. One resident described the texture of the meat in the casserole served at lunchtime like pork but it was chicken all those spoken to said the lunch served at the time of the inspection was better than usual. The inspector found a bowl of fresh fruit in the kitchen, which is not accessed by residents; residents were unaware that fresh fruit was available. The manager confirmed that Service Users are not offered fresh milk. All milk, including milk on cereals, in drinks and provided as a drink in it’s own right is reconstituted dried milk. Lunch was served at the time of the inspection and comprised Chicken casserole with green beans and cabbage with roast potatoes (none of the residents spoken to were aware of an option to this meal), followed by cheesecake or chocolate mousse. Afternoon tea was accompanied by chocolate cake. Residents and visitors told the inspectors that the food in the home had been excellent until the new owners took over and the chef left because he refused to cook frozen produce; one visitor said ‘the chef they had before they were taken over was excellent and there was good fresh food and milk’. The inspectors spoke to a number of visitors who were pleased with the visiting arrangements and said they were offered beverages and could order meals as well. Written feedback was received from 3 visitors all indicated they feel welcomed into the home at any time and are able to visit their relative/friends in private. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Not all people are aware of the complaints procedure or know who to talk to if they are dissatisfied, this poses the risk that some people may continue to have unresolved problems. The home does not have policies and procedures readily available and staff have not had training in recognising, responding to or reporting allegations of abuse this means that residents cannot have confidence that if they were to suffer abuse it would be dealt with in a safe and appropriate manner. EVIDENCE: The inspector found the complaints procedure within the statement of purpose, service users guide and contract/terms of residency; procedures in these documents were not consistent, the guide and contract did not make it clear to complainants that they could contact the Commission for Social care at any time, they actually indicate that the commission should only be contacted if the manager and provider have failed to deal with their complaint to their satisfaction. The inspector looked at complaints received and spoke with one complainant who had not had their complaint dealt with to their satisfaction and had been requested to put there complaint in writing which they had done in December but had not had a response in writing from the registered provider to date. The written feedback from 4 residents indicates if they were unhappy with their care 2 would know who to speak to, 1 wasn’t sure and the other indicated they would not know who to speak to. Written feedback from 3 relatives/visitors indicates only 1 was aware of the complaints procedure and only one had actually made a complaint. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 16 The 4 residents who provided written feedback, all indicated that they feel safe living in this home. The inspector asked to see the policies and procedures and was provided with a folder containing many policies and procedures dated 1996 a number of the policies inside the folder were dated 2001. There was no evidence of a copy of the local authorities and associated agencies adult protection procedures ‘the allerter’s guidance’ and training for staff in recognising responding to and reporting allegations of abuse has yet to be arranged. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Generally the environment is satisfactory the décor and furnishings are homely; there are areas of the home that would benefit from improvement. A few areas of personal accommodation were found to have offensive odours. EVIDENCE: Most areas of the home were seen during the inspection, with the exception of some private accommodation (bedrooms). The communal areas consist of a large conservatory lounge with diner attached these rooms benefit from natural light there is a smaller inner lounge which does not have natural light but is homely and comfortable. Since the new owners took over the running of the home 3 new call bells have been fitted in the conservatory, however these are not accessible to non- ambulant residents. One visitor said they would like to see pull bells in the lounges because the residents have no way of calling for anybody if they need assistance. A number of free standing radiators were found in the private accommodation of residents, the inspector was told by one resident that they had told the provider they were cold in their room the provider had got someone to bleed Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 18 the radiator in the room which had not improved matters and had also provided the freestanding radiator which was effective. The window in one residents room was faulty and found to be on a slant could not be closed or opened easily, this had also been reported to the owner who had said it would be replaced in the dry weather, but despite a spell of dry weather the window had not been attended to, the resident kept her curtains closed despite it being during the day to keep out the draft, the same residents room had been flooded because of a fault with the sani- flow WC in their ensuite accommodation, which the resident couldn’t access themselves because the hoist they needed to use for transfers could not be used in the en suite because of space confines. An engineer was called at the time of the inspection to try and rectify the problem with the unit. The carpet in another bedroom was badly stained and appeared to be rotting. Bedrooms were all seen to be comfortably and pleasantly decorated on an individual basis. Observation confirmed that Service users are given an option and were seen to provide their own furnishing. The inspector found the hot water supplied to wash hand basins on the first floor too hot to keep her hands under this may pose a risk to residents getting scalded. A number of bathrooms are available in the home, bars of soap were found in the bathrooms, this is poor practise as cross contamination is a high risk as micro- organisms like to exist in this type of moist and warm host. The hot water temperature was checked in one bath on the ground floor and was 41C within the accepted range for reducing risk of scalds. One bin being used for disposal of clinical waste in a resident’s bedroom was not pedal operated requiring staff to manually lift the lid also providing a risk of contamination. The inspectors noted three pans used with commodes were dirty with what appeared to be dried faeces the back of one commode was split. The laundry was seen to have a large build up of dust and debris on the machines, walls and pipes to the rear of the driers and washers, the laundry worker was unaware of any routine cleaning routines/policy. One visitor described the laundry arrangements as chaotic. The inspector found a recorded complaint had been made when a resident’s woollens had been ruined by the use of a hot wash the complaint had not been resolved to the complainants satisfaction with no apology being given. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There are not always sufficient numbers of staff on duty to meet the needs of residents. EVIDENCE: All of those spoken to during the inspection were extremely complimentary about the staff saying they are kind, hard working and thorough. Quotes included’ the staff are wonderful, kind and caring’ ‘ the staff are marvellous and friendly we have lots of laughs’. The 4 residents who provided written feedback indicated that they all feel well treated by the staff, feedback was also received from 3 relatives; 2 indicated that in their opinion there is not always sufficient numbers of staff, one stated they were ‘concerned that sometimes there are insufficient staff to look after the residents’. At the time of the inspection there were insufficient numbers of staff at lunchtime to assist all those residents who required to have assistance with their meal this meant in practise one resident was fed after the others had finished there meals. Relatives/visitors said they came in at meal times to assist their relatives/friends because they were aware how few staff there were available at meal times. A resident told the inspector that although they liked to get up by 10.00am and the staff were aware of this, they sometimes did not get up until after 11.30 and that lunch was often served late because residents were still being assisted to get up at lunchtime. There has been a high turnover of care, catering and domestic staff in the last 3 months, some new staff have been employed the residents said they like the Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 20 new staff and said it would take time for them to settle in and understand every ones individual needs. A registered nurse is on duty at all times and is usually supported by 4 care assistants in the morning, three in the afternoon and evening and 2 at night; the care assistants on duty at night assist with domestic duties such as the laundry. In addition there are catering and domestic staff as well as the manager employed at this home. A training programme was displayed in the office and indicates the following training is being provided between January and June: Fire prevention comprising a video and questionnaire, use of catheters and sheaths, promoting continence, eye problems in the elderly, Nutritional needs of the elderly, wound care management, moving and handling update and medication management. Information provided to the Commission by the manager indicates that 8 care staff have achieved a National Vocational Qualification in Care. The inspector looked at personnel records held on behalf of 3 members of staff, 2 files lacked evidence of Criminal Record Bureaux checks, one contained an application for a work permit, but there was no evidence it had been granted despite the staff member commencing work on 18/10/05. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,37,38 A new manager was employed in October 2005; the commission expects an application for their registration to ensure the person is ‘fit’ for the purpose of managing this home. EVIDENCE: A new manager was employed in October 2005; Maureen Dunkley is a first level registered nurse who informed the inspectors has a wide experience of both nursing and management. The residents and staff spoken to during the inspection were complimentary about ‘the matron’ and the inspectors found her helpful, polite and professional. It was disappointing that despite this inspection being announced there was no representation from the Registered provider although the inspectors were informed they could contact them by phone if needed. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 22 The manager/matron has introduced a number of audits to measure the effectiveness of systems including tissues viability, accidents and medication management. The policies and procedures seen were dated and there was no evidence to suggest they had been updated or reviewed by the new management team. All accidents were recorded and records showed evidence that a qualified technician has serviced the nurse call, fire alarm and emergency lighting systems. A fixed electrical installation check was performed in December 2005 and a 5-year certificate issued. A certificate of employers liability insurance was displayed in the home and is valid. The inspectors examined the records and storage of personal money held on behalf of residents in the home, three balances were checked against records and all were incorrect with larger balances than those recorded, there was little evidence that these are checked regularly and agreed by more than 1 person at a time. Whilst visiting the laundry the inspector spoke with the Laundry worker about the training she had received on substances that she was using in the machines, there were no COSHH leaflets in the laundry and the member of staff had not been provided with any information. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 23 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 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 3 3 2 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 X 2 2 Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP8 Regulation 12(1) Requirement Nutritional screening must be undertaken on admission and subsequently on a periodic basis, a record maintained of nutrition including weight gain or loss, and appropriate action taken. The routines of daily living and activities made available must be flexible and varied and suit the resident’s expectations, preferences and capacities. The registered person must ensure that residents are offered a choice of meals at lunchtime the choices must be communicated to them in written or other formats to suit their capacities, which is given read or explained to enable them to make a choice. The complaints procedure (however and wherever it is communicated) must include information for referring a complaint to the CSCI at any stage, should the complainant wish to do so. All staff must receive training on recognising, responding to and DS0000064645.V268026.R01.S.doc Timescale for action 01/03/06 2 OP12 16(m)(n) 01/03/06 3 OP15 16(2) 20/02/06 4 OP16 22 01/03/06 5 OP18 13(6) 01/04/06 Chollacott House Version 5.1 Page 25 6 OP24 16(2) reporting allegations of abuse. A clear policy and procedure including contact details of local agencies that must be informed must be available and communicated to all staff. The carpet in room 22 must be replaced. To ensure the right to privacy and dignity and security is available to people being admitted to the home, the registered provider must fit locks to bedroom doors as and when the rooms become vacant, All people living in the home must be provided with lockable storage space for medication, money and valuables and be provided with the key which they can retain (unless the reason for not doing so is explained in the care plan. Risk assessments must be performed on all radiators/heaters and where a risk is identified the radiator/heater must be fitted with covers or have guaranteed low temperature surfaces. Risk assessments must be performed on hot water outlets of wash hand basins that are accessed by residents and where a risk is identified, design solutions must be put in place to ensure the water is delivered close to 43C The floor and walls in the laundry must be made readily cleanable and dust and debris must be removed to reduce the risk of infective bacterial contamination. Soap bars must not be left in 01/03/06 7 OP25 13(4) 01/04/06 8 OP26 13(3) 01/04/06 Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 26 bathrooms if residents want to use soap bars a system must be in place, which, prevents more than 1 resident, coming into contact with the soap bar. 9 OP27 18(1) The registered person must ensure there are enough staff on duty to meet the needs of residents at all times. The registered person must not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of schedule 2. The registered person must apply to register a manager for the home with the Commission. 01/03/06 10 OP29 19(1)(b) 31/01/06 11 OP31 8 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP2 OP7 Good Practice Recommendations Information provided about the home to prospective and existing residents and/or their representatives must reflect actual practise. The statement of terms and conditions/contract should include specific information about the room(s) to be occupied Service user plans of care should be drawn up with the involvement of the service user, recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and or representative (if any) All staff should treat resident’s rooms as their private accommodation and should gain permission (Where possible) from the resident before entering. DS0000064645.V268026.R01.S.doc Version 5.1 Page 27 4 OP10 Chollacott House 5 6 7 8 9 10 OP14 OP19 OP20 OP21 OP26 OP30 11 OP35 12 OP37 13 OP38 Residents should be able to rise and retire at the times they chose. A programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced and implemented with records kept. An accessible system should be available in communal rooms for immobile residents to be able to summon assistance when staff are not in attendance. The WC in the en suite of room 23 needs to be fixed. Bins used for contaminated waste should be opened by a foot pedal A training needs analysis should be performed on all staff to ensure the staff team individually and collectively have up to date knowledge and skills to meet the needs of residents. The registered person should ensure that the records and storage of money held in the home on behalf of residents are secure and accurate. 2 people should sign each transaction and receipts must be kept. Spot checks should be performed to ensure balances are correct. Up to date policies and procedures should be available in the home and communicated to staff for the protection of residents and for the effective and efficient running of the business. All staff that come into contact with substances that could be hazardous to health should be provided with training and COSHH information for each product. Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Chollacott House DS0000064645.V268026.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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