Inspection on 17/07/08 for Le Chalet

This inspection was carried out on 17th July 2008.

CSCI found this care home to be providing an Good 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

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Poldhu

Queensmount

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Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Le Chalet Bickington Road Barnstaple Devon EX31 2DB Lead Inspector Sue Dewis Unannounced Inspection 17th July 2008 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Le Chalet DS0000070957.V365121.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. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Le Chalet Address Bickington Road Barnstaple Devon EX31 2DB 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) 01271 342083 01271 342083 Vijay Enterprises Limited Mrs Lorraine Anthonett Gail Gaunt Care Home 11 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (11) of places Le Chalet DS0000070957.V365121.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 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) Dementia (Code DE) The maximum number of service users who can be accommodated is 11. 2. Date of last inspection Brief Description of the Service: Le Chalet is registered to provide personal care for up to 11 older people in the who may also have a dementia type illness. The home is situated on the outskirts of the centre of Barnstaple, close to local amenities and facilities with public transport access nearby. It is furnished to a comfortable, high quality and attractive standard. All the accommodation is situated on the ground floor level and has been extended to provide 11 single bedrooms. Some bedrooms have direct access to the extremely well kept and cultivated gardens, while the main access is via the lounge. There are several small communal areas where people can spend their day, including a pleasant sun-lounge. There is a small parking area, which there are plans to extend. This was the first visit since the change in ownership of the home. An application is being processed to increase the numbers of people who may be accommodated at the home from 11 to 12. A copy of the report of this visit will be available on request from the manager, with a copy also being placed in the bookcase. Fees for the home currently range from £320 - £400 per week. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Le Chalet DS0000070957.V365121.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced visit took place over 8 hours, one day in the middle of July 2008. The service had been notified that a review was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the service has managed the quality of the care provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to people living at the home, health and social care professionals (including GPs and care managers) and staff. At the time of writing the report, responses had been received from 7 people living at the home, a visitor and 6 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 3 people living at the home were spoken with individually and 4 in a group setting. We also observed staff and people living at the home throughout the day. We spoke with one person’s representatives, 2 staff and the manager. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files What the service does well: Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 6 The home returned their AQAA (Annual Quality Assurance Assessment) when we asked them to, and they have continued to inform us of any reportable incidents that have occurred since the last visit. There is clear information available about the home, which means that people thinking of moving into the home have enough information on which to base their decision. Good admission policies and procedures ensure that no-one is admitted to the home whose needs cannot be met. Staff are aware of the needs of the individual and ensure they are met with respect and dignity. All risks are assessed and there is some evidence that the home works closely with healthcare professionals to ensure health care needs are met. A letter was received from a local Hospice Nurse who commented ‘The residents generally appear happy and their needs well catered for. My patient has received regular empathic and sincere care. The carers are doing such a great job’. The systems for administration of medication are good to ensure people are kept safe. Staff commented on their survey forms that ‘We provide a clean and happy environment to live in’, ‘…provide a safe, happy comfortable home for those unable to care for themselves’ and ….‘make sure people are happy, well supported, have a good diet and a clean and tidy environment’. There are some activities and entertainments on offer and good food is provided. People are offered some choices throughout the day and staff were hears asking people what they wanted. People feel the home is well managed and are able to discuss any concerns they may have. There are adequate staffing levels and staff receive regular training to enable them to continue to meet people’s needs. Robust recruitment practices ensure people are safeguarded from staff who may be unsuitable to work with vulnerable people. The home is well maintained, clean and safe and provides people with an nice place in which to live. What has improved since the last inspection? What they could do better: Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 7 Only one requirement was made at this visit and that is, that the Responsible Individual must visit the home unannounced at least once a month. A report must be made of this visit and a copy kept at the home. Throughout the visit, and detailed in the report, we discussed with the manager other areas for improvement, and include those detailed below. 1. The importance of providing more information in the AQAA (Annual Quality Assurance Assessment), so that it better reflects the improvements identified by the owners and manager. 2. The importance of ensuring that people’s care plans reflect their current needs and that there is evidence that these needs are being met. 3. That people should be enabled to go out of the home more on short trips. 4. That the ‘star’ locks on bedrooms doors should be replaced with locks that are approved by Devon and Somerset Fire Service. 5. That there should be sufficient staff on duty at all times to meet all the needs of people living at the home. 6. The importance of ensuring all radiators are covered in order to minimise the risk of people being burnt on the hot surfaces. 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. Le Chalet DS0000070957.V365121.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 Le Chalet DS0000070957.V365121.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, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures at the home ensure people have sufficient information on which to base a decision and assessment procedures ensure that their care needs can be met. EVIDENCE: There is good clear information available to anyone thinking of moving into the home. All 7 people who returned surveys felt that they had received enough information about the home to enable them to make a decision as to whether or not to move in. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 10 The files of three people living at the home were looked at including that of the most recently admitted person. All three contained pre-admission assessments that included health needs assessments and risk assessments. The manager told us that following a referral she will obtain as much information as possible and invite the person and their representatives to visit the home. She will then visit the person and complete the necessary assessments. The home does not provide intermediate care. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are generally well formulated and generally give clear information. However, more evidence is needed to show that people’s needs are being met. Medicines are stored securely and administered appropriately to ensure the safety of people living at the home. EVIDENCE: The files of three people were looked at during this visit. All three contained plans of care that generally gave staff good directions on how to meet the needs of the individual on a day to day basis. The plans showed evidence of regular review and some involvement of individuals and their representatives. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 12 The manager told us that they were in the process of changing the format of the plans and one of the files that was looked at was in this new format. However, the assessments for this new format were very basic and showed little detail of the needs of the individual especially in the areas of social history and hobbies. The assessments for the ‘old’ format were more detailed but the information from these was not always transferred into directions/information for staff. For example, one assessment (from January 2008) identified an individual’s behaviour as ‘very heavy’ indicating the need for a lot of input from staff, However, there were no instructions to staff as to how the behaviour of the person was to be managed. The manager said that the person’s behaviour had changed since that initial assessment, but the monthly reviews did not show this change. The daily records for each person were generally good and provided useful information for staff. However, there was little evidence of how people’s identified care needs were being met. Also there were instances where there was no evidence to show that issues had been followed up. For example one night time entry stated that a person had said they were hungry, but there was no record of what the member of staff had done about this. The manager and member of staff said that the person had received something to eat, but the member of staff thought this was too obvious to need to record it. The files also included details of visits from health care professionals. We were told by the manager that currently, a District Nurse is their only regular health care visitor, but that GP’s are always available on request. The policies and procedures relating to the receipt, storage and administration of medicines were looked at. All of these were all satisfactory and accurate records were seen. The home uses a monitored dosage system (MDS) supplied by a local pharmacy. All of the staff that administer medicines have attended a one day training course and their knowledge was tested at the end of it. A list signatures and initials of staff authorised to dispense medication is kept. The home does not currently hold any controlled drugs and no-one living at the home wishes to self medicate. Staff were seen offering personal care in a discreet manner, they spoke with people in a friendly and respectful way, and knocked on doors before entering. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that there are no plans for improvement in the next 12 months. Le Chalet DS0000070957.V365121.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers a reasonable range of activities and entertainments to stimulate and occupy people and links with visitors are good. However, there are few outings and this limits opportunities to support and enrich people’s social life. Meals provide nutritious variety and choice for individuals. EVIDENCE: Three people were spoken with in private and several others were observed and spoken with in the lounge. All appeared happy and relaxed, and good interaction that promoted wellbeing was seen between staff and individuals. Care plans show little social history or information on hobbies and interests. Therefore it is difficult to identify what type of activities people would enjoy. However, some activities are on offer including quizzes, and making cards. We were told that people enjoy the garden and we saw people walking in the garden during the visit. People told us (via surveys) that they enjoy the activities, but would like some musical instruments for when they have singLe Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 14 songs. An activities log is kept on people’s care plans and these showed evidence that people had participated in walking in the garden, quizzes, singsongs and exercises. There is no transport for the home, and this along with current staffing levels, means that people are rarely able to be taken out of the home. Staff commented (via survey forms) that they would like to be able to take people out on short trips and to shop. We spoke with one person’s representatives who said that they were always made to feel welcome at the home. They said that they felt their relative was very well cared for and that they often praised the staff to them and never had any complaints. They also said that the manager had helped to address some health issues that their relative had. We were told by the manager and also observed through the visit, that people are regularly offered choices. Choices include what time people get up and go to bed, what they want to eat and what they want to wear. Staff were heard offering choices of what was wanted to eat and drink throughout the visit. People told us that the food was very good with one person saying that they had recently put on weight. The manager told us that she draws up the menu based on what she knows people like. She said that everyone knows the likes and dislikes of individuals very well and that if they do not like something on the menu an alternative is always available. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to implement the report’s (from the visit of May 2007, under previous ownership) recommendations, which were - 1. It is recommended that the recreational and social likes/dislikes of each person living in the home is considered and activities planned to reflect individual needs and interests and, 2. It is recommended that you review the domestic arrangements at the home to make sure that staff always have enough time to care for the people living there. Le Chalet DS0000070957.V365121.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that any concerns would be dealt with appropriately and are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: We were told that there is a simple complaints procedure in each bedroom and a ‘suggestion box’ for the use of people living in, working at and visiting the home. However, the complaints procedure is not on display, which means people visiting the home would have to ask a member of staff for details of how to make a complaint. Although people were generally not able to tell us anything about the ‘complaints procedure’, they were able to say who they would talk to if they had any concerns, and felt that if they did they would be dealt with immediately. The representatives that we spoke with said that if they had had to raise only minor issues and that these had been dealt with straight away. Staff told us that they have received training in recognising and dealing with abuse. They were able to describe a variety of differing kinds of abuse, Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 16 including people not being kept warm, or not having enough to eat. Staff were aware of the correct procedures for reporting any suspicions to someone within the home and said that they would involve other agencies such as the police if they felt they needed to. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that there are no plans for improvement in the next 12 months. Le Chalet DS0000070957.V365121.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, 20, 22, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people with a good place in which to live, being clean, safe, comfortable and homely. EVIDENCE: The home is well maintained both internally and externally. It is comfortably furnished with fixtures and fittings that give it a homely and relaxed feel. During the visit a tour of the home took place. Some bedrooms were seen as well as communal areas, toilets and bathrooms. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 18 The bedrooms that were looked at each had personal possessions displayed and reflected the personalities of the occupant, and people are encouraged to bring items into the home with them to enable them to feel at home. The rooms contained all the items that individuals require in order to have their needs satisfactorily met. Bedroom doors are fitted with ‘star’ locks and while these give individuals some degree of privacy, this is limited, as all locks have the same key. There is also the concern that someone could get locked in their room from the outside and may not be able to get out. This matter was discussed with the manager and she will look into fitting suitable locks to the doors that are approved by Devon and Somerset Fire Service. People spoken with during the visit were happy with the standard of the accommodation. This was also confirmed in surveys and comments included ‘The home is kept very clean and always a fresh smell when you come in’. Le Chalet has a beautiful garden that is well maintained and provides a quiet and peaceful area for people to sit in. This includes a lawned area, shrubs, trees and flowers. There are several seating areas and a pond with fish in which some people like to feed. People are also helping to grow vegetables. There is a variety of moving and handling equipment available to staff, including a bath hoist, a mobile hoist a turntable and a handling belt. Staff said that they receive regular training in moving and handling. The laundry is small but is suitable to deal with the laundry from the home and has an impervious floor to minimise the risk of cross infection from soiled laundry. Staff said that had received training in infection control procedures and that disposable gloves and aprons were always available. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to improve the layout of the grounds and the car parking area. Le Chalet DS0000070957.V365121.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of staff available throughout the day and night are generally sufficient to meet the needs of the people currently living at the home. The procedures for the recruitment of staff are robust and offer full protection to individuals. EVIDENCE: Staff rotas indicated that there is a minimum of two staff on duty at all times, and that sometimes the manager is supernumerary. However, the staff that are on duty are also required to cook meals and clean the house. This means that there is sometimes only one member of staff readily available to meet the needs of the individuals. This also limits the possibility for people to go on trips out of the home. People that we spoke with said that sometimes they had to wait for quite a while for assistance as staff were often busy. Staff commented (via surveys) that ‘It would be nice if residents could go out on little trips’ and (it would be Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 20 better if there were) more staff so that they have time to sit and chat with people’. However, people were full of praise for staff and survey forms contained many positive comments including, ‘I am very happy and well looked after’, ‘Very happy and contented’ and ‘I am very happy and well looked after’. Three staff files were looked at. All contained proof of identity, two references, recent photographs of the staff member, and evidence that satisfactory police checks had been obtained. Staff told us (certificates were seen) that they had received training in POVA (Protection of Vulnerable Adults), Moving and Handling, Basic Food Hygiene, Infection Control and Fire Precautions. Four staff have obtained NVQ (National Vocational Qualification) level 2 or above and another is working towards NVQ level 2 or above. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to provide staff with training in dementia care issues. Le Chalet DS0000070957.V365121.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 and 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 well managed resulting in practices that promote and safeguard the health, safety and welfare of people living and working at the home. EVIDENCE: This was the first visit to the home following a change in ownership to a company. The new owners also own another home and have several years experience of working with older people. Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 22 The manager has only recently been registered with the Commission, but has worked at the home for many years with the previous owners. She has obtained NVQ level 3 and the Registered Managers Award. Staff said that they felt well supported and commented (via surveys) that the ‘manager is always ready to help if you have any problems’ and ‘the management are doing a great job’. The manager told us that surveys had been sent out to all interested parties asking for their views on the quality of care provided by the home. The owner indicated on the submitted AQAA (Annual Quality Assurance assessment) that the current quality assurance system for the home was being changed in line with the Commission’s guidance on our website. Where the registered owner of a service is a company the Responsible Individual (a nominated representative of the company) is required to visit the home unannounced and to write a report on the visit, a copy of which must be kept at the home. Copies must also be sent to the Commission if requested (Regulation 26 Care Homes Regulations 2001). Guidance on this matter is available on the CSCI website. The manager told us that the Responsible Individual for the owning company was supportive and visited the home on a regular basis. However, there was no record of these visits, or of any issues that were identified during the visit, kept at the home. Three individual’s financial records were looked at. The systems for recording transactions are good, helping to ensure their financial interests are safeguarded. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Le Chalet complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. However, there was a discussion with the manager about some of the evidence contained within the AQAA. On several occasions the AQAA indicated that there was no need to improve the service, as the previous report did not identify any requirements or recommendations. The Commission expects that owners and managers identify for themselves, through their quality assurance system, any areas for improvement. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 23 risks to people living and working at the home. Staff confirmed that they have received training in fire precautions as well as Health and Safety. So that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. However, there is only one radiator that is fitted with a cover. The manager said that there was a programme in place to ensure all radiators were covered eventually. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection indicates that in order to improve the service the home intends to issue the Quality assurance questionnaire bi-annually and to have a staff suggestion box. Le Chalet DS0000070957.V365121.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 2 X 3 STAFFING Standard No Score 27 2 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 Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 25 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 OP31 Regulation 26 Requirement The responsible individual must visit the home unannounced at least once a month, prepare a report of the visit and leave a copy at the home. Timescale for action 03/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 26 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 Le Chalet DS0000070957.V365121.R01.S.doc Version 5.2 Page 27 - 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!