Inspection on 02/06/08 for Chorlton Place Nursing Home

This inspection was carried out on 2nd June 2008.

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

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

Chorlton Place Nursing Home 12/06/07

Chorlton Place Nursing Home 16/05/06

Chorlton Place Nursing Home 15/02/06

Chorlton Place Nursing Home 18/08/05

Chorlton Place Nursing Home 03/11/04

Chorlton Place Nursing Home 26/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Chorlton Place Nursing Home 290 Wilbraham Road Chorlton Manchester M16 8LT Lead Inspector Geraldine Blow Unannounced Inspection 10:00 2 & 4th June 2008 nd 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 Chorlton Place Nursing Home DS0000021637.V363292.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. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chorlton Place Nursing Home Address 290 Wilbraham Road Chorlton Manchester M16 8LT 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) 0161 882 0102 0161 860 6685 www.schealthcare.co.uk Southern Cross Healthcare Services Ltd Veronica Amadi Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users requiring nursing care shall be 45. The maximum number of service users requiring personal care only shall be 3. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 issued on 3 June 2001. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 12th June 2007 4. Date of last inspection Brief Description of the Service: Chorlton Place Nursing Home provides accommodation for 48 older people. The premises are owned by Nursing Home Properties (NHP) PLC and are leased to Southern Cross Healthcare Limited. The home is located in the Chorlton area of Manchester close to main public transport routes, local shops, public houses and other social and recreational amenities. Parking facilities are available to the front and rear of the property. The home is a three storey purpose-built building set in its own wellmaintained grounds. Bedroom accommodation for residents is provided on the first 2 floors and the third floor is used as office space, which includes the companys divisional offices. The home offers accommodation in 48 single, ensuite bedrooms. Each floor has 2 lounges, a dining room and 2 small seating areas. The charges for fees range from £388.31 to £568 per week. There are additional charges for magazines, papers, hairdressing and Chiropody. Chorlton Place Nursing Home DS0000021637.V363292.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 1star. This means the people who use this service experience adequate quality outcomes. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 12 June 2007 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and relatives were sent comment cards. At the time of this visit 1 resident comment card was received by CSCI. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. This visit forms part of the overall inspection process and took place on Monday 2 June and Wednesday 4 June 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with the manager, several people living at the home, members of staff and a tour of the building was undertaken. Feedback was given to the manager during the course of this visit and on conclusion of the visit. What the service does well: The home is clean and provides a pleasant environment for the people who live there. There is a well maintained, enclosed garden to the rear of the property. As detailed in the previous inspection report the menus seen showed that a variety of healthy meals were provided. The nutritional value of each meal is calculated to make sure that it contains all the required nutrition. The menus are on display for everybody to see. In the returned comment card the resident indicated that they usually liked the meals as did most of the residents spoken to during the visit. Residents are encouraged to maintain contact with their family and friends. Residents and staff spoken to all said that visitors can come whenever they like and are made to feel welcome Systems are in place to support people to raise any concerns they have. Details of how to make a complaint are on display in the main reception and the Service User Guide is also available in the main reception, which contains Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 6 the complaint procedure. In the returned comment card the resident indicated that they knew how to make a compliant as did the residents spoken during the course of this visit. On the first day of this visit some residents were seen going for a day out to Southport. There was a programme of varied activities displayed on both floors of the home. In the returned comment card the resident indicated that activities are always arranged by the home. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 7 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 Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 8 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&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all prospective residents needs are thoroughly assessed prior to being admitted to the home. EVIDENCE: A corporate pre admission assessment form is in use to assess prospective residents care needs prior to admission. However in the majority of care files inspected during this visit the dementia assessment had not been completed, even though the residents did have some specific needs. To ensure that all prospective residents assessed needs can be met all sections of the pre admission assessment must be fully completed, with particular reference to the Dementia assessment. Three out of the four pre-admission assessments had not been signed or dated by the person completing the assessment. To ensure accountability it is Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 9 recommended that that all assessments are signed and dated by the person completing them. An intermediate care service is not provided at Chorlton Place. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 10 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. Some shortfalls were identified in ensuring that all the care needs of residents were being met. EVIDENCE: A sample of care plans was seen and 4 residents were case tracked. The care files examined all contained a plan of care, although some shortfalls were identified. Not all of the residents identified care needs had been incorporated into the care plan, with particular reference to mental health/ challenging behaviour needs. For example one plan of care identified that the resident was ‘aggressive to other residents’. The manager confirmed that this particular resident was also aggressive to staff. This had not been included in the care plan and there were no details of how staff should best manage the aggressive behaviour. In addition another care plan identified that the resident had suicidal/self harm thoughts and a care plan had not been implemented to address this care need. Following a discussion with the manager a plan of Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 11 care was implemented the following day. Other care files examined detailed that the resident could be aggressive to staff but again there was no details of how the behaviour should be best managed. To ensure that the health and welfare of residents is fully met and other residents and staff are not put at risk a detailed plan of care must be implemented for each identified care need. Some parts of the plans were vague and did not clearly set out the actions which needed to be taken by staff to ensure that resident’s health and personal care needs are met. For example some entries included, ‘hoist to be used’, ‘give daily shower’ and ‘wedges to be used’. There was no description of exactly what assistance was needed, which hoist or sing should be used or where the wedges were to be placed. In addition entries such as “occasionally she wet her bed and pants” and “toilet and keep her dry” were seen. These entries are not person centred and do not promote or preserve the dignity of residents and this was discussed with the manager on both days of this visit. It is recommended that that all resident’s care plans are developed using a person centred approach and contain sufficient detail for staff to meet all resident’s identified needs and personal preferences. In order to promote the dignity of residents it is also recommended that the terminology used in the care plans is reviewed. The plans of care had been reviewed on a monthly basis but in some instances they had not been updated to reflect the review. For example a care plan had not been updated to reflect the advice of a professional visitor and another had not been updated regarding weight recordings and diet and fluids recordings. To ensure that resident’s needs are fully met it is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. Risk assessments were seen in the care files examined. However some risk assessments had not been undertaken in relation to the use of ‘lap’ belts and the use of the ‘bucket’ chair. However following a discussion with the manager the use of the bucket chair was risk assessed the day after the first visit. The use of restraints such as lap belts and restrictive chairs must be thoroughly risk assessed prior to their use. Records relating to the recording of dietary and fluid intake were examined. Two fluid records were being kept for residents who were on thickened fluids. Both sets of records seen contradicted each other and therefore an accurate record was not being maintained. There were gaps in the recording of the dietary intake and the records did not reflect the amount of food and drink taken and therefore an accurate record was not being maintained. To ensure that residents are receiving adequate fluids and nutrition an accurate record must be maintained. In addition it was noted that in some instances staff were signing ‘all staff’ or ‘staff’ when recording the dietary and fluid intake. It is recommended that staff sign their own name when recording resident’s diet and fluid intake. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 12 Evidence was seen that residents were registered with a local General Practitioner (GP) and evidence of GP visits. There were arrangements in place to access other health care professionals if needed. The records regarding medication were examined. There were no gaps in the recording of medication, in the records examined, with the exception of ‘thick and easy,’ which is used to thicken drinks and soups for residents with a swallowing impairment and some topical cream. Evidence was seen that the thickened drinks were being signed for on a separate sheet and the manager confirmed that the cream was also being signed for separately. If medication is being signed for separately the medication record should clearly cross reference to where there is an accurate recording. It was noted that some medication was prescribed as “apply to the affected area” and “take as directed as required”. To ensure that residents receive median as indented by the GP confirmation of the prescribers’ intentions must be sought and documented. Surplus, unwanted or expired medicines were appropriately documented and stored while waiting to be picked up by the waste management company. It was noted that a medication with a limited life e.g. eye drops had the date of opening documented to ensure out of date medication is not given to residents. Evidence was seen that medication audits continue to be undertaken. From talking to the manager and staff it appeared that specific religious and cultural needs of residents could be met and several examples were given. As already identified in this report some of the written terminology did not fully promote the dignity of residents and a photograph was seen that was very exposing and did not preserve the dignity of the resident. However residents and staff spoken to confirmed that privacy and dignity was respected during day-to-day interactions and residents are encouraged to exercise choice in their daily lives. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise control over their day-to day lives and activities were provided. EVIDENCE: The home employed the services of a full time activity coordinator. There was an activity board on both floors displaying the activities available. Some of the activities were armchair aerobics, tea dances, shopping, arts and crafts, bingo and afternoon movies. The manager confirmed that the activity coordinator keeps a record of what activities the residents attended. On the first day of this visit several residents and staff were seen going to Southport for the day. Residents spoken to confirmed that regular activities were available and one resident described a recent barbeque. All people spoken to confirmed that the home facilitated open visiting and all confirmed that visitors were made to feel welcome. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 14 From speaking to residents and staff it appeared that residents are encouraged to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. The “Nutmeg” system continued to be used. This consists of the nutritional value of the meals being calculated, to ensure that it is satisfactory to meet resident’s needs. A bar chart is then produced, which is on display in the main reception, next to a copy of the menu. This is considered good practice. The menu offered a variety of wholesome and nutritious meals, which included home made cakes mid afternoon, platters of fruit and a selection of suppers. A hot meal is available at each mealtime and staff and residents confirmed that a choice of meals is also available at each mealtime. Staff and residents stated that if residents did not like what was on the menu then they could have any reasonable alternative. The returned comment card indicated that the meals provided were good. The dining areas are clean, bright and inviting. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Systems are in place to enable people to raise concerns and polices and procedures are in place to protect people from abuse. EVIDENCE: There are details of how to make a complaint on display in the main reception and the Service User Guide is also available and contains the complaint procedure. There is a record of verbal concerns and complaints made, which included details of the complaint, any staff statements and copies of any correspondence and an outcome of the investigation. There is a ‘monthly complaints monitoring audit form in use and there is a general ongoing log of complaints and concerns. Evidence was seen that if concerns are raised they are discussed with the key worker. This is seen as good practice. The manager confirmed that she has an open door policy and encourages people to raise any concerns or complaints. In addition details regarding a weekly managers ‘surgery’, where the manager is available to see anybody who would like to speak to her, was on display in the main reception. The returned resident comment card stated that they knew how to make a complaint and residents spoken to said that if they had any worries they would go to Veronica, the manager. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 16 There were corporate policies and procedures, in relation to the protection of adults from abuse and evidence was seen of ongoing staff training, which was confirmed by staff spoken to. Since the last inspection the home had appropriately responded to an allegation made. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment, including the standard of hygiene, was well maintained both internally and externally. EVIDENCE: As part of this visit a tour of the building was undertaken which included all the communal areas and several bedrooms. The home was clean, tidy, well decorated and furnished to a good standard. There were no offensive odours and residents and staff confirmed that the cleanliness of the home was always of a good standard. The received resident comment card indicated that the home was clean and fresh. Since the last inspection visit there has been ongoing improvements to the décor and furnishings of the home. The reception area has been refurbished, the ground floor has been repainted and new carpets have been laid. New Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 18 lounge chairs, coffee tables and several new beds have been bought. The manager said it was their intention to now focus on the decor on the first floor. The bathrooms and the majority of toilets have had a make over, by staff making them more homely and attractive in appearance. The rear garden is well maintained and pleasant for residents to use when the weather is nice. There is attractive garden furniture and a gazebo is available for sun protection. New more secure side gates and a fence have been installed for added security around the garden area. Many of the bedrooms had been personalised with resident’s own belongings. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 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. 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. Adequate numbers of staff are provided and the recruitment and selection process protected residents from potential abuse. EVIDENCE: From direct observation and reviewing records kept it appeared that there were sufficient staff employed to meet the needs of the number of residents accommodated. The manager confirmed that 29 care staff are employed and 8 care staff have successfully completed NVQ Level 2 and a further 5 staff are currently undertaking the training. The recruitment records were looked at for three members of staff who had been recruited since the last inspection visit. They contained the required documentation as required by Schedule 2 of The Care Homes Regulations 2001. Evidence was seen of POVA first and Criminal Records Bureau (CRB) checks. The manager confirmed that all original documents are kept in a secure place. It is recommended that a record of the CRB certificate number, type and date be kept on record and the original can be destroyed. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 20 Staff files contained photocopied documents, for example passports and certificates. However on the majority of photocopies there no evidence that the original documents had been seen. It is recommended that that all photocopied documents are signed and dated to indicate that the original has been seen. The manager confirmed that the NMC website is checked when nurses PINs are due for renewal and for suspension or exclusion from the register. The manager confirmed that all new staff must complete the corporate Induction Programme which is followed by a supervision session. Evidence of this was seen in the files looked at. There was a staff training Matrix and each member of staff has an individual training record. Evidence was seen of a 6 month staff training plan which included Moving and Handling, Fire Training, Catheter Care, Dignity, Respect and Diversity, Medication, Continence, COSHH and POVA. The training for Caring for the Confused resident had been cancelled, due to sickness, but the manager stated that it was her intention to rearrange the training. The manager confirmed that following some of the training a competency assessment is undertaken in the form of a questionnaire to ensure that staff have understood the training provided. This is considered good practice. Staff spoken to all stated that training was available and that the manager encouraged and support them to undertake training. One member of staff said that she found her job much more enjoyable after training as she had a greater level of understanding. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interest of residents who live there. EVIDENCE: The manager is registered with CSCI and is supported through the organisation by the operations manager. She has the skills, experience and qualifications to manage the home. Residents and staff benefit from a committed manager who operates an open management style and encourages residents, visitors and staff to make use of the ‘open door’ policy. Residents spoke highly of the manager and one said, “Veronica is great, she sorts everything out”. Staff spoken to all said that they felt supported by the manager. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 22 There is a corporate quality questionnaire that is sent out on a regular basis and ‘opinion questionnaire’ that is available in the reception area in an attempt to gain peoples’ views of the service provided. However the manager stated that the response rate to these is generally poor. In addition to these formal tools the manager confirmed that feedback regarding the service delivery is obtained via the managers and staff discussions with relatives, visitors and discussions with visiting professionals. To ensure that standards are maintained the manager undertakes monthly audits, for example care plans, medication, statutory records, for example fire records, and staff training. In addition to this the operations manager undertakes validation audits and feeds back to the home’s manager with the results. Evidence was seen that the systems in place safeguarded resident’s financial interests. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Evidence was seen that the fire safety records were all up to date and regular fire drills are undertaken. In accordance with the Care Homes Regulations 2001 information is supplied to the commission of events which adversely affect the well being or safety of any resident. However it was noted that we did not receive such information regarding a particular incident for 25 days. The commission must be informed without delay of all instances detailed in Regulation 37 of The Care Homes Regulations 2001. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 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 X X 2 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 3 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 3 X 3 X 3 X X 3 Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 (1) (a) Requirement To ensure that all prospective residents assessed needs can be met all sections of the pre admission assessment must be completed, with particular reference to the Dementia assessment. 1. To ensure that the health and welfare of residents is fully met and other residents and staff are not put at risk a detailed plan of care must be implemented for each identified care need. 2. The use of restraints such as lap belts and restrictive chairs must be thoroughly risk assessed prior to their use. In order to evidence that residents are receiving adequate nutrition and are adequately hydrated, with particular reference to residents who require thickened fluids, an accurate record must be kept of all food and fluids provided. To ensure that residents receive DS0000021637.V363292.R01.S.doc Timescale for action 01/07/08 2. OP7 12(1) (a) 13 (4) (c) 01/07/08 3. OP7 17 (2) Schedule 4 (13) 01/07/08 4. OP9 13 (2) 01/07/08 Page 25 Chorlton Place Nursing Home Version 5.2 5. OP31 37 (1) (e) their medication as intended by the GP clear directions must be sought and documented when medication is prescribed without clear instructions. To meet their responsibilities under the Care Homes Regulations 2001 the registered person must inform the commission without delay of any event which adversely affects the well being or safety of any resident. 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP3 OP7 Good Practice Recommendations To ensure accountability it is recommended that that all pre admission assessments are signed and dated by the person completing them. 1. It is recommended that the residents individual plans of care be more person centred and contain more details of the specific action which needs to be taken by staff to ensure that all individual aspects of residents health, personal and social care needs are met. 2. In order to promote the dignity of residents it is also recommended that some of the terminology used in the care plans is reviewed and rewritten. 3. It is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. 4. It is recommended that staff sign their name when recording residents diet and fluid intake. 3. OP9 If medication is being recorded separately to the medication recording sheet it is recommended that the DS0000021637.V363292.R01.S.doc Version 5.2 Page 26 Chorlton Place Nursing Home 4. OP29 medication record should clearly cross reference to where there is a signed accurate recording. It is recommended that that all photocopied documents are signed and dated to indicate that the original had been seen. Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Chorlton Place Nursing Home DS0000021637.V363292.R01.S.doc Version 5.2 Page 28 - 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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