Inspection on 06/05/08 for Chypons

This inspection was carried out on 6th May 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chypons 20/04/10

Chypons 28/04/09

Chypons 05/12/07

Chypons 15/06/07

Chypons 21/03/07

Chypons 31/05/06

Chypons 21/03/06

Chypons 16/06/05

Chypons 09/11/04

Chypons 13/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Chypons Clifton Hill Newlyn Penzance Cornwall TR18 5BU Lead Inspector Ian Wright Unannounced Inspection 6th May 2008 09:00 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 Chypons DS0000055781.V364017.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. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chypons Address Clifton Hill Newlyn Penzance Cornwall TR18 5BU 01736 362492 01736 360399 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) Mr Geoffrey Walden Knights Miss Donna Louise Norton Care Home 27 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (27) Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) maximum 27 places Dementia aged 65 years and over on admission (Code DE(E)) maximum 3 places Mental disorder, excluding learning disability or dementia, aged 65 years and over (Code MD(E)) maximum 3 places The maximum number of service users who can be accommodated is 27. 5th December 2007 2. Date of last inspection Brief Description of the Service: Chypons provides accommodation and personal care for up to 27 older people, three of who may have dementia and a further three who may have a mental illness upon admission. The home is situated in the village of Newlyn, near to Penzance and is easily accessible by road. All the amenities of the village and town of Penzance are close by, although there is quite a steep hill leading up to the home. There is ample car parking space for visitors in the homes grounds. The home consists of two inter-linked wings. Most of the bedrooms are for single occupancy and have en suite bathrooms. The main lounge and several of the bedrooms have spectacular sea views. There is a large lounge/ dining room and hairdressing/beauty salon. There is a small, paved terrace area on the upper floor to enable people who use the service to sit outside if they wish. The home has a lift to enable people who use the service to access the upper floor. The entrance to the building has suitable access for people with disabilities. The home has equipment and grab rails at strategic points to assist people with physical disabilities. The home is privately owned and the registered provider employs a manager to Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 5 assist him to run the home. A team of care staff, including senior carers and ancillary staff provide care and support to people who use the service. At the time of the inspection fees range from £375-£550 per week. Additional charges are made for hairdressing, newspapers and personal items. A copy of this inspection report is available via the home’s management or the CSCI website. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over seven and three quarter hours in one day. All of the key standards were inspected. The methodology used for this inspection was: • To case track five people who use the service. This included interviewing the people who use the service about their experiences and inspecting their records. • Interviewing three care staff about their experiences working in the home. • Informal discussion with staff and other people who use the service. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. • Assessing ‘Adult Safeguarding’ (adult protection) procedures and practices in the home, as part of a CSCI national survey. Other evidence gathered since the previous inspection such as notifications received from the home (e.g. regarding any incidents which occurred) were used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? What they could do better: Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 7 This inspection has resulted in ten statutory requirements. Action regarding these legal requirements is required within the timescales set. In summary, requirements have been made regarding: • Care planning • The medication system • Ensuring bathroom and toilet facilities so they are all lockable • Ensuring there is soap at wash hand basins. • Staff training, and to develop an ongoing training programme. • Improving recruitment and personnel information obtained when staff are employed. • Making sure there is a satisfactory hot water supply to all areas of the home • Health and safety precautions. • Quality assurance systems so there are not shortfalls regarding the above matters. The commission will monitor the registered persons to ensure satisfactory improvements are achieved. 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. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information provided to people who use the service (e.g. regarding what service is offered, and individual assessment of need) is appropriate. This will help ensure people who use the service, and their representatives, have satisfactory information regarding the rights and responsibilities, and what service they can expect. EVIDENCE: The registered persons have an assessment policy and this is satisfactory. Copies of pre admission assessments were contained on the files of people living in the home. All people who use the service have been issued with a statement of terms and conditions of residency / contract. Copies of this documentation are available on the files of people who use the service. The service does not provide intermediate care. Chypons DS0000055781.V364017.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. Health and personal care standards are generally satisfactory, although some improvement is required to care planning and the management of medication. People who use the service and their representatives said they were happy with the care provided. EVIDENCE: Care plans for some people who use the service were inspected. Although adequate, and contain suitable information to assist staff to provide care, some improvements to the system are required. The registered manager is in the process of introducing a new care planning system. This seems ‘person centred’, but some of the sections within the format still need to be completed for many people’s plans. Importantly all care plans need to have a photograph attached to them. A clear record of when people last saw medical professionals e.g. chiropodist, dentist, optician, GP, CPN etc. should be included. This will enable staff to track that people receive regular medical support and people do not get ‘lost in the system’. ‘Life story’ / Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 11 resident profile work should also be completed. Where there is a higher risk of scalding (e.g. from hot water or surfaces) for individual people who use the service (e.g. if risk of falling, and or people with dementia) this should be risk assessed as part of their care plan. The review process appears satisfactory, although more detail regarding review should be included. Although some people who use the service did not appear to be aware of their care plans, all people who the inspectors spoke to said they received appropriate care and support according to their wishes and needs. Health care support appears to be satisfactory. People who use the service said they had access to relevant external professionals when necessary. The medication system was inspected. Medication is stored in cupboards and a locked trolley, in a locked medication room. Medication is administered via a monitored dosage system. Despite a requirement issued at the previous inspection on 5th December 2007, improvements to the operation of the system are still required: • There were some dosages of medication which were signed for but did not appear to be administered. • Some medication was not signed for but appeared to be administered. Better systems need to be in place to avoid this occurring. Staff who administer medication appear to have received appropriate training in this area, although no certificate was available on some files. People who use the service were very positive about care and support delivered by staff. Staff were seen as ‘nice’, ‘helpful’, and people said they would have confidence in approaching staff if they had a problem. The inspector observed people who use the service receiving appropriate levels of support, and staff enabled people who use the service to have suitable levels of choice about how they spent their time, what food they wanted etc. A requirement was made at the last inspection regarding staff having training regarding the needs of people with visual impairments. Internal training is being delivered regarding this matter and needs to be completed for all staff. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 12 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. Appropriate arrangements are in place so people who use the service can enjoy a lifestyle that meets their needs. Food provided is to an excellent standard so people enjoy a choice of good quality meals that meet nutritional needs. EVIDENCE: There is a pleasant, relaxed atmosphere in the home. People were observed having a choice when they got up. Despite one member of staff being sick on the day of the inspection, staff on duty managed the shift well, and staff support was observed as being professional, relaxed and unhurried. Some organised activities are offered. There are occasional bus trips, singing sessions and keep fit. The registered manager said she was also conducting a survey to ascertain what further activities could be offered. Two people who the inspector spoke to did not appear aware of any activities on offer. They said however that they did not wish to participate in activities. However, as necessary, staff should do their best to ensure all people who use the service are aware of any activities offered. Interests regarding educational, therapeutic, for recreational and social activities for people should be recorded in individual care plans. People who use the service said they could receive a Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 13 daily newspaper if they wished. There are suitable opportunities for people to receive visitors when they wished either in the lounge or in their bedrooms. There are fantastic views from most rooms in the home which people said they very much enjoy. Records regarding monies kept on behalf of people who use the service were inspected and were satisfactory. Staff do not act as appointee for government financial benefits, for any of the people who use the service. Records are kept of fees paid to the registered provider. There are facilities for valuables to be looked after on behalf of people who use the service. People who use the service said they felt their personal belongings were safe, and said nothing that belonged to them had disappeared. Each bedroom has a safety deposit box. A minority of people who use the service have a lock on their bedroom doors. Management have said to us previously that all new people admitted to the service would be offered this facility. Existing people who use the service have been asked if they want a lock on the door. Where people have said no, or this is not appropriate due to people’s mental health needs, this has been recorded in their files. The inspector shared a meal with people who use the service, on the day of the inspection. Food served was of good quality, and there is a genuine choice of two meals at lunch time. The meal on the day of the inspection was either stew and dumplings, or sausages and vegetables. This was followed by apple crumble. Similarly there was a choice of hot tea either of fish pie or sausage pie, followed by a sweet. Staff support was to a high standard. People who use the service all said they were content with the food provided. They said there was always enough food and people said meals are well cooked. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. A suitable complaints procedure is in place, but the adult protection procedure needs some revision. Improvement of this procedure should help in assisting people who use the service have more assurance regarding adult protection processes at the home. EVIDENCE: There is a suitable complaints procedure. The registered persons or Commission for Social Care Inspection have not received any complaints regarding this service. People who use the service said they had no concerns, complaints and allegations about the service. They said they would feel confident approaching staff or management if they had any problems. The adult protection policy needs some development. The policy needs to state the correct procedure if there was an allegation of abuse e.g. the matter should be reported to Cornwall County Council Department of Adult Social Care. Incidents, where appropriate, should be reported to the police if a criminal offence may have been committed. As noted in the policy, CSCI should be informed. It would be helpful if the telephone number of these organisations is included in the policy. Staff, people who use the service, and management seemed generally aware of what to do if there was an allegation of abuse. It is however important staff Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 15 read the policy, when corrected, as part of their induction. There was information produced by the county council regarding abuse in the lounge and also on the staff notice board. Once corrected it may be helpful if the policy was also on the staff noticeboard. The registered manager confirmed there had been no allegations of abuse, and they had not had to refer any ex members of staff for inclusion on to the Protection of Vulnerable Adults Register. Employment records for all staff showed appropriate checks had been completed on staff employed since the last inspection. The majority of staff have now received training regarding the awareness of abuse. The training programme regarding this matter needs to be completed for all staff. None of the staff, who the inspector spoke to, said they believed there were any incidents of abuse or bad practice at the home. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 16 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, 21, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Environmental standards are generally satisfactory although some improvement is still required to ensure there is a satisfactory supply of hot water in all areas, and carpets are kept clean where possible. Suitable accommodation ensures people living at the home can enjoy a comfortable home life. EVIDENCE: The building was inspected. On the main floor there is a large through lounge and dining room. This has spectacular sea views of Mounts Bay from the town of Penzance to Newlyn Harbour. There is a small outside seating area where people can enjoy the view. Furnishings in the lounge are quite old, but the room is comfortable, inviting and homely. There were fresh flowers, books and magazines around the room, and the room is a pleasant and relaxed place to spend time in. Toilet and bathroom facilities are generally suitable. Assisted bath facilities are available for people with mobility problems. The majority of the communal Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 17 bathrooms and toilets now have a lockable door. However a lock still needs to be fitted to, for example, the bathroom opposite ‘Unit one’. Locks on bathroom / toilet doors ensure people who use the service have privacy when they are bathing or going to the toilet. The registered provider assured the inspector this matter would be addressed at the last inspection in December 2007, however it is still outstanding and needs to be attended to. Although two people only use the facility, it is a shared facility, and people are entitled to appropriate privacy. There was also no soap in at least two bathrooms / toilets. This has a potential impact on cleanliness and infection control. The registered manager said soap is provided at wash hand basins, but can disappear. If necessary, wall mounted soap dispensers should be fitted. There are still outstanding issues regarding problems with the hot water supply in a minority of bedrooms, but the registered manager has assured the inspector this matter will be resolved shortly. The requirement regarding this matter is however renotified. A risk assessment has been completed regarding the risk of scalding. Where there is a higher risk for individual people who use the service, this should be risk assessed as part of their individual care plans. The registered manager said hot water from baths is now thermostatically controlled. Decorations are generally satisfactory, although some areas, for example, in parts of the corridors some redecoration will be required shortly. There are a number of interesting pieces of sculpture around the home, and interesting paintings in a modern style. The home has two lifts. One lift links the ground floor with the lower floor, and a second lift links the ground floor to the first floor. There is also a staircase. A short chairlift allows people with mobility problems to access two of the bedrooms. One of the lifts was broken on the day of the inspection, the maintenance company was awaiting a part and the lift would be repaired in the next few days. People affected could apparently still make their way around the building. All bedrooms are for single occupancy, and eighteen have an ensuite toilet. Many have lovely sea views, and all are generally well furnished and decorated. However some of the furnishings are beginning to look worn and will need gradual replacement in the short to medium term. There are suitable laundry and kitchen facilities. People who use the service were positive regarding the facilities provided. The registered persons have said people who use the service had been asked if they wanted a lock on their bedroom doors. The registered persons have said locks have been provided where requested. People subsequently admitted to the service will be offered this facility. This should be documented during the admission process. The building was generally clean and hygienic on the day of the inspection. However the inspector noted that some carpets in several of the bedrooms Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 18 need cleaning. This has been noted now on previous inspections, and it is essential there is a suitable deep cleaning programme in place to minimise the problem. Some of the carpets in the corridors also are beginning to look soiled and worn. The registered manager said that carpets in some of the bedrooms, where a problem was mentioned, will be replaced shortly. Chypons DS0000055781.V364017.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and recruitment procedures are satisfactory. There have been improvements regarding staff training, however some further work still needs completing so people who use the service can be assured staff employed have received training as required by law. EVIDENCE: On the day of the inspection satisfactory staffing levels appeared to be provided i.e. the rota showed four care staff were on duty during in the morning, three care staff in the afternoon and two care staff in the evening. There are also two staff on waking nights. This seemed satisfactory considering the current number of people accommodated and their current needs. In addition ancillary staff (cooks, cleaners) were on duty. People who use the service were positive regarding the support they received from staff. Personnel and training records of eight care staff were assessed. Pre employment checks were satisfactory. For example staff had two written references (except for one person who was employed in 2006), and a Protection of Vulnerable Adults / Criminal Records Bureau check. A copy of documentation verifying a person’s identity should be retained on file- as required by the Care Homes Regulations 2001. However, the registered persons must have seen this documentation in order to process the person’s Criminal Bureau Record check. A statement by the person as to their mental and physical health also needs to be included in the application form as Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 20 required by the regulations, and to verify the person is physically and mentally fit enough to work in a care home. The staff team have undertaken a considerable amount of training since the last inspection in December 2007. For example most staff have now received training regarding infection control, fire awareness and dementia awareness. Senior staff were receiving Appointed Person first aid training on 8/5/08 (i.e. soon after the inspection). Junior staff have also recently undertaken ‘First Aid Awareness’ training. By law all staff must have: • Regular fire training in accordance with the requirements of the fire authority. • There must always be at least one first aider on duty (at appointed person level). • All staff must have manual handling training. • All staff must have basic training in infection control. • If staff handle food they must receive training regarding food hygiene. • All new staff must have an induction and there should be a record of this. There are still some gaps in all staff receiving this training, as is required, and a requirement has been made to ensure staff receive outstanding training required. Subsequently, it is essential the registered persons put in place a more ‘proactive’ approach to ensure staff receive training required by law, and according to the needs of the people who use the service. It is important a training policy is developed which outlines what training staff require, and when, in the duration of employment. The registered manager said she does not intend to train staff regarding food handling as all food is handled by either cooks or kitchen assistants. This is acceptable as long as no food is handled by care staff (e.g. making a sandwich). However, if care staff do handle food e.g. in the evening or if the cook is sick, they must be trained appropriately. For example some senior staff have undertaken the ‘Safer Food, Better Business’ training developed by the Food Standards Agency, and kitchen staff have Food Hygiene certificates. If care staff do handle food, and as long as the Environmental Health Department are happy, the Food Standards Agency guidance can be cascaded to care staff (refer to the section regarding training in the guidance). However, the registered persons do need to liaise with the Environmental Health Department to ensure this is acceptable to them before commencing such an approach. The registered persons have a suitable approach to enabling staff to have the opportunity to obtain a national vocational qualification (NVQ) in care. Currently of the 17 care staff, 7 appear to have an NVQ (41 ). Some staff are currently completing an NVQ. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 21 There is suitable evidence that staff receive induction training. A new member of staff commenced employment on the day of the inspection, and was observed being shadowing a more experienced member of staff. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been a lot of improvements to this service over the past year. However there is still some work to do to ensure the quality assurance process satisfactorily monitors some key areas of the service such as health and safety standards. These measures will ensure people who use the service can be assured they live in a service which is safe and has a sustained record of improvement. EVIDENCE: The registered provider Mr G Knights lives locally and is present at the home several times a week. Ms Donna Norton is the registered manager. Both seem pleasant, and keen to provide good care for the people who use the service. The registered persons have developed a quality assurance policy which is satisfactory. A survey of the views of people who use the service, and the views of their relatives, has been completed and this is satisfactory. Some further monitoring needs to take place by management to ensure some of the Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 23 regulatory issues highlighted in the report are monitored, either maintained or improved. Management subsequently need to consider refining their systems to ensure there are improvements in some areas (e.g. management of medication, environmental standards, staff training and health and safety). How management do this should be included in the organisation’s quality assurance policy. Management of the monies of people who use the service is satisfactory as outlined under NMS 14. The registered persons has a satisfactory health and safety policy. The home has a fire risk assessment, which was completed in November 2007. Emergency call points for the fire system appear to be tested appropriately. However emergency lighting- essential if there is a fire- still does not appear to be tested appropriately according to records. For example the system was last tested, according to records, on 14th March 2008. However it appeared to be regularly tested between the last inspection and that date. According to records the fire system was last serviced in January 2008, and fire extinguishers in April 2008. Health and safety risk assessments appear satisfactory. There is a risk assessment regarding the prevention of legionella. The passenger lift was last serviced in on 23/4/08, although it was not working on the day of the inspection. The stair lift was serviced in October 2007. Gas appliances were serviced in September 2007. Moving and handling equipment and the Parker bath have been serviced. The registered manager said they have had a long wait to get the electrical circuit tested, but contactors are due ‘this week’. The registered persons are required to forward a certificate to the Commission when this work is completed. Suitable evidence of portable electrical appliances is also required. Suitable insurance for the building and people using it appears to be in place. Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 24 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 3 3 X X X 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement All people who use the service should have a comprehensive care plan. Matters outlined in the body of the report need to be addressed. This will help to ensure the needs of people who use the service are addressed. (Timescale of 01/04/08 not met 2nd Notification) Medication needs to be managed in accordance with the Royal Pharmaceutical Society Guidelines. Matters raised in the text of the report need to be addressed. This will ensure the medication of people using the service is managed appropriately. (Timescale of 01/04/08 not met 2nd Notification) Management need to introduce appropriate monitoring procedures to ensure the system works effectively. The current adult safeguarding / protection policy needs development as outlined in the report. A copy of the revised policy should be provided to the commission when completed. DS0000055781.V364017.R01.S.doc Timescale for action 01/09/08 2. OP9 13(2) 01/06/08 3. OP18 13(6) 01/09/08 Chypons Version 5.2 Page 26 4. OP21 13(4), 23(2)(j) 5. OP21 13(4), 23(2)(j) 6. OP24 13(3), 23(2)(d) The programme of adult protection training for all staff needs completing. Both measures will give further assurance to people who use the service that they are protected from poor practice and abuse. There must be a satisfactory hot 01/09/08 water supply available in bedrooms, toilets and bathrooms. These measures will ensure a suitable water supply is available to people living in the home. (Timescale of 01/04/08 not met 2nd Notification) The registered persons must confirm in writing when appropriate work has been completed. All bathrooms and toilets must 01/09/08 be lockable (with an overriding facility as necessary). Soap must also be available in bathrooms / toilets. These measures will ensure people who use the service are provided with private and hygienic toilet / bathroom facilities. Where possible, all carpets must 01/06/08 kept clean. This will help ensure people who use the service enjoy a pleasant and clean environment. (Timescale of 01/02/08 not met 2nd Notification) Recruitment records for care staff employed from the date of this report must: • Have evidence on file to confirm the person’s identity. • Have a statement by the person as to his/her mental and physical health (e.g. as part of their application form.) DS0000055781.V364017.R01.S.doc 7. OP29 19 01/06/08 Chypons Version 5.2 Page 27 8. OP29 18. 19 9. OP31 OP33 7, 9, 12, 13, 24 10. OP38 12, 13(4), 23 These measures will assist in providing appropriate evidence individual staff are fit persons to work in a care home. The registered persons need to: 01/12/08 1. Develop a training policy, outlining what training staff will receive and when during the duration of their employment. This needs to include all training required by law. A copy of this needs to be provided to CSCI within 6 months of the date of this report. 2. Ensure all current staff employed complete the current training plan within 3 months of the date of this report(e.g. where gaps exist on the training matrix supplied to CSCI) 3. Provide CSCI with an update of training provided to all staff within 6 months of the date of this report. These measures will ensure staff receive training required by law and to meet the needs of people who use the service. Further develop the quality 01/09/08 assurance system to monitor standards regarding medication, the environment, staff training, health and safety. Ensure measures to be taken are included in the quality assurance policy. This will help minimise risks to staff and people who use the service. 01/09/08 Health and safety precautions need improvement: 1. Emergency lighting must be tested at intervals recommended by the fire authority. Provide evidence to CSCI that this is being completed DS0000055781.V364017.R01.S.doc Version 5.2 Page 28 Chypons regularly by the deadline. (Previous timescale of 31/3/08 not met-Third Notification) 2. Ensure the electrical hardwire circuit is tested at least every five years, and a safety certificate is obtained. A copy of this must be forwarded to the commission. (Previous timescale of 31/3/08 not met-Second Notification) 3. Provide evidence to CSCI that portable electrical appliances have been serviced in the last year. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Chypons DS0000055781.V364017.R01.S.doc Version 5.2 Page 30 - 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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