CARE HOMES FOR OLDER PEOPLE
Chy Byghan Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX Lead Inspector
Paul Freeman Unannounced Inspection 5th June 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 Chy Byghan DS0000062587.V298645.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. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Chy Byghan Address Chy Byghan Sunny Corner Lane Sennen Penzance Cornwall TR19 7AX 01736 871423 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) Mrs Jacqueline Brown Mrs Rosemary Ann Deane Mrs Rosemary Ann Deane Mrs Rachel Mary Vaughan Care Home 19 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (19) of places Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: Chy Byghan is a registered care home providing accommodation and personal care for up to nineteen older people. Up to six of the residents may require care because they experience confusion. The home also provides day care for up to three older people. The home is detached and is located in the village of Sennan, approximately 11 miles from Penzance. It is situated slightly off the main road and has car parking space. The building consists of two storeys, with most of the accommodation provided on the ground floor. Several of the residents bedrooms have French doors that open directly onto an outside patio. All the bedrooms currently have single occupancy but two rooms can be shared if required. The home provides a comfortable sun lounge, a smaller second lounge and a well-decorated, spacious dining room. The registered providers live at the care home and one provider is the registered manager. Both providers play an active role in running the home on a day-to-day basis. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. A planned unannounced inspection took place on 5 June 2006 and 7 June 2006. The inspection considered the key elements of the services and facilities provided which included care planning, health and safety, staffing arrangements and meals. The environment and a number of records and documents were also considered. The residents, staff and the person in charge of the home were also consulted. Two relatives were also consulted as part of the inspection. The Providers had also sent written information to the Commission about the services and facilities provided. Both providers were on holiday when the inspection took place and were therefore unable to contribute. Kind thanks are given to the residents and staff and visitors to the home for their cooperation and assistance at inspection. What the service does well:
Health needs of residents are well met and medical services are accessed promptly when required. Residents said they had confidence in the staff who they found to be diligent in making sure there were no outstanding health issues. Residents were also very positive about the care and support provided and the dignified manner they are treated by staff. A weekly programme of activities is in place and some of the residents are very satisfied with the arrangements. Additional opportunities to enable residents to experience community outings are being planned and the providers are currently arranging to access transport on regular occasions. Many of the residents are satisfied with the food and the choices available. The residents said that meals were prepared to a good standard and commented that “healthy” portions were provided. Satisfactory arrangements are in place to deal with any complaints or concerns. Residents were confident there are no barriers to raising issues and were sure any concerns would be dealt with satisfactorily. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 6 A suitable adult protection policy and procedure is in place to protect residents from abuse and any allegations or concerns are reported to the statutory authorities for investigation. The home is a detached property and has sea views on two aspects. The environment and facilities are well maintained and provide a comfortable setting for residents. Residents said they were satisfied with the facilities. The majority of the accommodation is provided on the ground floor and comprises of two sitting rooms, a dinning room and residents bedrooms. Three bedrooms are also located on the first floor and are accessed by stairs or a stair lift. Bathrooms and toilets are distributed throughout the home and within a reasonable distance from communal areas and residents bedrooms. Some of the resident’s bedrooms also have ensuite facilities and many rooms have been personalised by the occupants. The house keeping staff maintains a good standard of cleanliness and hygiene and residents stated the home is always clean. Residents said they were very satisfied with the manner in which staff undertook their duties. Waking night staff is on duty each night and reliable arrangements are in place for additional staff to be called upon in an emergency. Staff at the home said it was an enjoyable place to work and they were well supported by colleagues and the managers at the home. The staff said there was a good team spirit and the staff worked well together. The appointment of a senior carer to assist the providers in the running the home is seen as a positive resource to provide a good standard of care and support to the residents. There are also other good examples of practise in relation to the management of the care home. Where residents are assisted to manage their personal allowance the providers have established appropriate arrangements to make sure their money is kept safely. Suitable records are also made of each transaction. What has improved since the last inspection?
The care planning arrangements continue to improve. Residents are regularly consulted about their care plans to make sure all their needs are met in a satisfactory manner. Some of the current care plans need to have more information to make sure a clear picture about the care and support required is provided.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 7 The plans are regularly reviewed with the residents and their relatives or representatives but the records of the review need to be more detailed. This will also make sure that up date and comprehensive information is available. The provider have reviewed and developed the arrangements to store and administer medicines following the last inspection. The arrangements are more robust but further improvements in the record keeping is recommended. This will make sure that comprehensive and clear directions are provided to the staff. The record keeping arrangements continue to improve but there are occasions where records required by regulation are incomplete or lack sufficient detail. The risk assessment and risk management arrangements also continue to be developed. Further improvement is required in order that every reasonable step is taken to promote safety and eliminate risk. What they could do better:
The providers assess each prospective resident to make sure they are able to meet the needs, preferences or choices of the person concerned. As part of the assessment the providers meet with the prospective resident and consult relatives or representatives. The views of any professionals that are involved with the person are sometimes taken into account. The assessment information is not complete or sufficiently detailed for the providers to be satisfied they are able to meet the needs of the person concerned. More information also needs to be collected to make sure the providers have a clear picture of the care and support required so that a suitable care plan can be established. The indications are that certain staff do not always follow the medication policy and procedure that has been established by the providers. This needs to be addressed to make sure that robust arrangements are in place and that resident’s health is not potentially compromised. Some of the residents are not satisfied with the recreational opportunities currently provided and relatives are concerned that the current programme of events does not always occur. These residents wish to have a more varied and stimulating lifestyle. Certain residents were dissatisfied with certain aspects of the menu provided which they said did not meet their preferences or tastes. Two relatives also commented the meals could be improved and were particularly concerned that “home made cakes” did not appear to be on offer as regularly as had occurred in the past.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 8 Certain records were not available for consideration given the providers’ absence and the person in charge was not able to access the records concerned. The documents included complaint documentation and staffing records. Arrangements need to be put in place to make sure the providers comply with their regulatory responsibilities. The water temperature from certain hot taps around the care home appeared to exceed the minimum temperature required. This matter requires urgent attention to make sure that residents’ safety is not compromised. The providers following a review had increased the staffing levels for weekend mornings to make sure that residents’ needs were met. A staff member has recently been absent due to illness and it appears that the additional staffing measures at weekends are not always in place. This needs to be addressed to make sure residents needs are met. The fire safety arrangements need to be improved and developed to make sure that every reasonable step is taken to safeguard residents and staff. 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. Chy Byghan DS0000062587.V298645.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 Chy Byghan DS0000062587.V298645.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. The assessment arrangements are not satisfactory as insufficient information is obtained to provide a clear picture of needs, preferences and choices. This also limits the provider’s ability to be satisfied they are able to meet the needs of the prospective resident. EVIDENCE: The providers assess each prospective resident before they move to the care home. This is designed to make sure the providers are satisfied they are able to meet the needs of the prospective resident. The current assessments summarise the needs, preferences and choices of the prospective resident. Where necessary the most suitable means of providing the care and support required by the person are also considered. Relatives or representatives are also consulted and the views of any professionals involved with the person are sometimes taken into account. It is recommended that comprehensive information be obtained where a speaclist assessment has been completed.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 11 It is evident the providers meet with prospective residents but the records of the assessment were incomplete and do not provide sufficient detail in certain areas to satisfactorily provide a comprehensive picture of the persons needs, preferences and choices. The limitations of the information also restrict the provider’s ability to make sure the home is able to meet the needs of the person concerned and to develop a suitable plan of care. Residents that had recently moved to the care home confirmed they had been consulted prior to the move and had being given the opportunity to visit the care home. The residents also said they had received a positive welcomed from the staff and residents when they moved to the home. The providers do not offer a dedicated interim care or rehabilitation service but every reasonable effort is made to promote each residents independence. Chy Byghan DS0000062587.V298645.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The care planning arrangements do not provide a comprehensive picture of the residents needs to make sure residents receive the care and support required. The plans are regularly reviewed but the records of the review need to be more detailed to make sure up do date information is available. Positive arrangements are in place to meet and promote residents health needs. The arrangements to administer prescribed medicines have improved but the records could be developed further and staff are said to not always follow the policy and procedure laid down by the providers. This could potentially compromise the health of residents. EVIDENCE: Each resident has a care plan to inform the staff of the needs they have and the best way of providing the care and support they require. The care plans have improved following the last inspection but continue not to provide a comprehensive picture of each residents needs.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 13 Where residents are unable to direct their own care more information is required to make sure the care provided is safe and occurs in the most satisfactory manner. In some of the plans insufficient or no information was provided about the resident’s needs and preferences. Care plans need to provide sufficient detail to give staff the information, guidance and direction they require to provide appropriate levels of care and support. The care plans are regularly reviewed with the residents but the records of the review need to be more detailed. This will ensure that everyone at the care home has up to date information about the care and support required. The providers continue to develop and improve the care planning arrangements. Staff commented they found the plans to be informative and helpful in their work. Residents said that they were generally satisfied with the care and support provided but a number were able to identify areas that could be improved upon. These areas often related to the current lack of information, direction and guidance to staff. Residents were very satisfied with the manner in which their health needs are met. During the inspection District Nurses and a General Practitioner visited the care home. The records at the home indicate that health services are promptly accessed when required. In addition residents said they had confidence their health needs were met sensitively and efficiently. Following the last inspection the providers have reviewed and improved the arrangements to dispense medicines. Residents are able to administer their own prescribed medication where they wish and providing it is safe to do so. Where staff assist residents the medicines are kept in secure facilities and the staff have all been suitably trained. The records have also improved but in some instance further improvements could occur to make sure a detailed and comprehensive record is in place. Any medicines that are no longer required are disposed of safely and the providers have established a positive relationship with a Pharmacist. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 14 Generally residents had confidence in the manner medicines were dispensed but some residents indicated that certain staff do not always follow the providers policy and procedure. Residents are all very satisfied with the manner in which they are treated and were very complimentary about the staff and the care and attention they receive. Residents said that staff always treated them in a respectful and dignified manner. Chy Byghan DS0000062587.V298645.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are satisfied with the lifestyle they experience and are able to have control over their lives. Some residents want the recreational opportunities developed in order they can experience a more varied and stimulating life. Visiting arrangements are flexible in order that residents can maintain their relationships. A varied and balanced diet is planned and some residents are satisfied with the choice available. Other resident’s preferences are not fully met and this requires improvement. This will make sure that residents receive a varied and balanced diet that reflects their choices and tastes. EVIDENCE: Many residents are satisfied with the lifestyle they experience and commented they felt in control of events. There are a range of recreational and leisure opportunities provided at the home that reflect residents’ choices and preferences. Some of the residents said they were satisfied with the arrangements but others expressed an interest in broadening the opportunities available. Senior staff stated that negotiations were occurring to regularly access transport for residents to have more community links.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 16 Two relatives said that the current programmed activities did not appear to always take place and both commented the programme has been in place for sometime and would benefit from a review. It was not possible to determine the frequency that activities occur given no records were available for consideration. It is also noticeable that the information in residents care plans about leisure interests was limited. There are flexible visiting arrangements in place and residents are able to determine where they meet with their visitors. Residents aid that visitors were always welcome and well received by the staff. A varied menu is provided and two cooks are employed. Care staff also assist in the preparation of some meals ands the staff concerned have been appropriately trained. Both cooks are experienced and have been appropriately trained. The equipment in the kitchen is regularly serviced and maintained and appropriate health and safety measures are in place The majority of the residents are satisfied with the food provided but some said the menu could be improved in order that their personal tastes and preferences are better provided for. Two relatives also commented they believed the menu could be improved to better reflect their relatives’ needs and preferences. In addition the relatives commented there appeared to have been a reduction in the frequency that “home made cakes” and fruit were avlaible. This was viewed as a service reduction. . Chy Byghan DS0000062587.V298645.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Satisfactory arrangements are in place to deal with any complaints or concerns raised and appropriate arrangements are in place to protect residents from abuse. Records about complaints and required by regulation must be available for inspection “at all times”. EVIDENCE: The providers or the Commission have received a total of five complaints over the last year of which three have been fully upheld and two partially. The providers dealt with the complaint efficiently and took appropriate action to overcome any shortfalls identified. The providers have established a suitable policy and procedure to deal with complaints and residents said there were no barriers to raising any issues or concerns. The log and documentation were not available for inspections given the providers were on holiday and the person in charge did not have access to the documents. The policy and procedure in place to protect residents from abuse has been improved in the last year to make sure it reflects the Department of Health guidance ‘No Secrets’. Any allegations or concerns are reported to the statutory authorities and investigations takes place where necessary.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 18 In the last year there have been no concerns about abuse. A satisfactory whistle blowing policy and procedure is in place for staff. This gives staff with the opportunity to raise any issues of concern with a third party and provides additional protection for residents. Chy Byghan DS0000062587.V298645.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. The environment is well maintained, clean and hygienic and provides comfortable facilities for the residents. In certain facilities the hot water temperature appears to exceed the minimum standard required. This warrants urgent attention to make sure reside ts safety is not potentially compromised. EVIDENCE: The environment is well maintained, clean, pleasant and hygienic. Residents said they were very satisfied with the facilities, which they described as comfortable and homely. The property is detached and has sea views on two aspects. The majority of the accommodation is located on the ground floor and this includes the two sitting rooms and the dinning room. Two of the bedrooms are located on the first floor with a bathroom and toilet within a close proximity. These rooms are accessed by the stairs or a stair lift. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 20 Bathroom and toilets are also situated throughout the ground floor and within a reasonable distance from residents’ bedrooms and the communal areas. Some of the bedrooms are also provided with ensuite facilities. The residents’ rooms are well proportioned and many of the residents have personalised their rooms. A range of disability equipment is provided at the home to assist residents to maintain their independence and also to promote their safety. In addition individual residents are provided with disability equipment where this is required and following an appropriate speaclist assessment. Residents said the providers promptly responded to any repairs that were required but currently they do not keep a record of the action that has been taken. In certain areas the hot water in the communal bathrooms and certain ensuite facilities was found to be hot and did not appear to comply with the standard required. This requires urgent attention to make sure that residents’ safety is not potentially compromised. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. The staffing arrangements need further review given the long term illness of a staff member and the apparent reduction in staffing levels for some weekend morning. A review needs to occur to make sure that sufficient staff is on duty at all times to meet the needs of residents. The other key standards were not considered given the records were not available for inspection. EVIDENCE: Three core standards qualifications, recruitment and staff training were not considered given the records were not available for inspection. The requirement set at the last inspection to improve the recruitment arrangements is therefore renotified. The staff said they had received regular training but no staff member was aware if they had an individual training plan for the year ahead. The staff stated they were well supported and said assistance, support and advice was readily available. The providers have reviewed the staffing arrangements at weekends following the last inspection to make sure that sufficient staff is on duty at peak times. This resulted in additional staff employed each weekend morning for two hours to make sure that residents’ needs were met. It was reported to the Inspector
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 22 the additional staffing was not provided on certain occasions given one member of staff long term absence. The arrangements therefore need further review to make sure that residents’ needs are not potentially compromised. Residents were very positive about the manner in which the staff undertake their duties and the standard of the care and support provided. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. There is evidence of positive management arrangements at the home but the arrangements for periods of absence by the providers are not sufficiently robust. This could negatively impact on the services and facilities provided. Quality assurance measures were not considered given the records and documents were not available for inspection. Where assistance is given the providers manage residents’ personal allowances appropriately. This enables residents to have access and control of their personal allowances. A number of records at the home provide insufficient information or are incomplete to make sure that residents’ needs are met. Measures are in place to provide residents with a safe and hygienic environment. The arrangements for assessing and managing risks need to be improved to safeguard residents.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 24 EVIDENCE: Both providers play a key role in the management of the care home and in the direct provision of care and support to residents. One of the providers acts as the registered manger and is currently completing the Registered Managers Award. Residents said they were satisfied with the management arrangement and stated they found the home to be well run. The recruitment this year of a senior carer that has previously worked at the home has further enhanced the residents’ confidence in the management arrangements. The staff also said they found the arrival of the senior carer had positively impacted upon the service provided to residents. Relatives also commented they had confidence in the manner in which the care and support provided were managed. The arrangements in place to manage the care home for times the providers have an absence need to be improved to make sure the person in charge has access to all the records and documents they may require. The arrangements regarding the quality assurance measures were not considered given the records and documents were not available for consideration. The providers will assist residents to manage their personal allowances if this is required and suitable records are maintained. The records detail the transactions that have taken place and a running balance is maintained. Each transaction is signed by one the providers. It is recommended that where residents are unable to sign a second signature be obtained. The providers continue to improve the records at the home. However there continue to be certain instances where the records are incomplete or provide insufficient information, guidance or direction to staff. Appropriate policies and procedures have been established to promote safe working practises at the home that are also designed to protect residents. The equipment and services at the home are regularly maintained and where necessary equipment is replaced. Fire precaution measures are also in place but the fire risk assessment is very brief and requires more detailed information. The records also indicate that fire training and fire drills are not occurring regularly and the fire equipment is not regularly monitored to make sure it is operating correctly.
Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 25 There is some improvement in the other areas of risk assessment and risk management. The assessments must however provide clear guidance to staff about the steps they need to taken to minimise any potential risks to themselves or residents . Any situations that arise that could potentially compromise a resident’s health; safety or well being must be assessed. This will make sure that all unreasonable risks are positively managed and provide residents with greater protection. Potential risks must also be taken account of during the assessments of prospective residents. Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 26 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 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 2 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 X 2 2 Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation Requirement Timescale for action 30/07/06 14(1)(a-c) A comprehensive assessment of need must be completed for all prospective service users. (Previous timescale of 30 March 2006 not met). 15(1) Care plans must provide sufficient information about the service users needs to inform, guide and direct staff. Staff must follow the policy and procedure regarding the storage and administration of medication. A range of recreational activities must be provided that reflect service users needs, preferences and choices. (Previous timescale of 30 March 2006 not met). 2. OP7 30/08/06 3. OP9 13(2) 13/06/06 4. OP12 16(2)(m) 30/08/06 5. OP15 16(2)(i) 6. OP25 12(1)(a) 13(4)(a) Residents must be provided with 30/07/06 a balanced and varied nutritional diet that reflects their preferences and choices. The water temperature from taps 30/07/06 must not exceed 43 degrees.
DS0000062587.V298645.R01.S.doc Version 5.2 Page 28 Chy Byghan 7. OP27 (c) 18(1)(a) Sufficient numbers of staff must be on duty at all times. (Previous timescale of 30 April 2006 not met). The documents detailed in schedule 2 must be in place as part of the robust recruitment, selection and vetting arrangements. Appropriate and robust management arrangements must be in place for all times the registered providers are absent from the care home. Robust and reliable management arrangements must be place for all occasions the providers are absent from the acre home. Effective quality assurance measures must be in place and an annual report completed and made available to service users and the Commission. (Previous timescale of 30 May 2006 not met). 30/07/06 11. OP29 19(1)(ac)sch 2 30/08/06 12. OP31 10(1) 30/06/06 14. OP31 10(1) 30/07/06 13. OP33 24(1-3) 30/08/06 14. 15. OP37 17(3)(b) OP37 16. OP38 Records required by regulation must be available for inspection “at all times”. 12(1)(a) Comprehensive records required 17sch 3, 4 by regulation must be maintained. 13(4)(a-c) Risk assessments must be completed on each occasion the safety or welfare of the service users could be compromised. 13(4)(a-c) Any action required from the risk 15(1) assessment must be included in the service users care plan. 23(4)(a) A detailed fire risk assessment must be in place.
DS0000062587.V298645.R01.S.doc 30/07/06 30/09/06 30/08/06 17. OP38 18. OP38 30/06/06 30/09/06
Page 29 Chy Byghan Version 5.2 19. 20. OP38 OP38 23(4)(a) 23(4) (d-e) Fire equipment must be regularly 30/06/06 monitored and suitable records maintained. Fire drills ands fire training for 30/08/06 staff must regularly take place according to the good practise guidelines. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Wherever possible detailed assessments should be obtained from speaclist workers for all prospective residents. A record detailing the contents and conclusions of each review should be made. The records relating to the administration of medication should be completed in a clear and consistent manner to avoid any potential misunderstandings. Where the providers assist a resident to manage their personal allowances ands the residents is not able to sign the record a second signature should be made. 2. 3. OP7 OP9 4. OP35 Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Chy Byghan DS0000062587.V298645.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
