Inspection on 02/02/06 for Seven Rivers Cheshire Home

This inspection was carried out on 2nd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Seven Rivers Cheshire Home 19/11/07

Seven Rivers Cheshire Home 28/11/06

Seven Rivers Cheshire Home 26/07/05

Seven Rivers Cheshire Home 03/02/05

Seven Rivers Cheshire Home 10/06/04

Seven Rivers Cheshire Home 04/02/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Seven Rivers Cheshire Home Hall Road Great Bromley Colchester Essex CO7 7TR Lead Inspector Gaynor Elvin Unannounced Inspection 2nd February 2006 11:30 Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 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 Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. 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. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Seven Rivers Cheshire Home Address Hall Road Great Bromley Colchester Essex CO7 7TR 01206 230345 01206 231011 severrivers@east.leonard_cheshire.org.uk www.leonard-cheshire.org.uk Leonard Cheshire 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 Gillian Mary Sleightholm Care Home 28 Category(ies) of Physical disability (21), Physical disability over registration, with number 65 years of age (11) of places Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 18 years and over, who requiring nursing care by reason of a physical illness/disability (not to exceed 21 persons) People with a physical disability who may be aged over 65 years (not to exceed 11 persons) No more than five persons may attend the home on a daily basis in addition to those 28 accommodated 26th July 2005 Date of last inspection Brief Description of the Service: Seven Rivers is part of the Leonard Cheshire Foundation. It is a care home registered to provide nursing and personal care to adults and older people who have a physical disability. The home originates as a Georgian style mansion and has a 1960s extension and a further extension built in the 1990s. The main house is a two-storey building with access to the upper floor provided by a passenger lift. Seven Rivers is located in the small rural village of Great Bromley, geographically central to the larger towns of Colchester and the seaside towns of Clacton on sea and Harwich. However public transport is minimal although a bus route runs past the home, which serves the surrounding villages. The local train station is in a neighbouring village of Gt Bentley approximately three miles away. Gt Bromley village has a local shop and public house. The home is set in large well-maintained grounds. The main house provides a flat for accommodating visitors for overnight stays and a flat for volunteer over sea GAP students Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on one day in February 2006, over five hours. All of the key standards and the intended outcomes have been assessed in relation to this service during at least two inspections for the current inspection year (April to March). To view the assessment of standards and outcomes not included within this report, please refer to the previous published report dated 26th July 2005. The inspection process included discussion with the Registered Manager, the Care Supervisor, the training co coordinator, informal discussion with care workers and examination of records, staff files and residents’ files. The inspector was invited to have lunch with the residents and would like to thank the cook and staff for their hospitality and the residents for their company. Everybody at Seven Rivers approached the inspection process in a positive and helpful manner. For the purpose of this report service users will be referred to as residents, this being the preferred form of reference. What the service does well: What has improved since the last inspection? The Statement of Purpose had been revised and brought in line with the legal and good practice requirements of the Care Homes Regulations 2001and the National Minimum Standards, providing important and relevant information about Seven Rivers to current and prospective residents. Progress has been made with regard to developing effective quality monitoring and assessment systems by the implementation of resident satisfaction Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 6 questionnaires. Response’s had been analysed and evaluated for future practice recommendations. Planned redecoration and refurbishment had been carried out in the dining room, according to resident’s choice, since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 &4 The service operates a responsible pre admission assessment process and care and attention is given to ensuring appropriate admissions. The home promotes the opportunity to visit the home as an essential part of the admission process. Resident’s receive a warm welcome and are provided with clear and relevant information regarding the service. EVIDENCE: The Statement of Purpose was reviewed on this occasion and had been updated to meet a requirement identified at the last inspection. The document reflected the aims and objectives of the service and informed prospective service users of the services and facilities offered. It is recommended that the Statement of Purpose and other documentation containing information about the home is also available in large print for those individuals with visual impairment. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 9 One new service user expressed satisfaction with the way the admission process was managed and with the way the home was meeting their needs. The resident had met with the manager in hospital prior to admission and was able to discuss fully future arrangements to meet identified needs and the type of care required. Written and verbal information was supplied and although the individual was unable to read the Statement of Purpose due to a sudden deterioration in eyesight, it was impressed that verbal information received was concise and appealing. The resident confirmed a visit to Seven Rivers, prior to admission, met with his expectation and the home accurately fitted the managers’ description. The friendliness, warm atmosphere and the beautiful grounds available at Seven Rivers prompted choice for admission. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 The care plans encompassed clear objectives, action plan, review and continuing evaluation; there was scope for developing a more person centred approach to the care planning process to include all each aspect of the persons identified needs and how they are to be met. EVIDENCE: The care planning process encompassed clear objectives, action plan, review and continuing evaluation; and had progressed with regard to content, identifying a clear plan of care to meet personal and most healthcare needs. However, the care plans examined did not reflect a holistic approach and emotional and psychological needs were not identified or planned for. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 11 Residents spoken with were unaware of their care plans but considered that they were able to make decisions about their lives and contribute to the decision making process with regards to meeting their care needs. Staff supported them and gave assistance where necessary. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 & 17 Social activities were focused, well organised, creative and fun; and provided stimulation and interest for everyone living in the home. Residents found the lifestyle experienced matched their expectations and needs. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 13 The home supplied sufficient quantity and good quality meals although more attention needs to be given to choice with regard to specialised diets. EVIDENCE: The activities coordinator and volunteers support residents to participate in leisure pursuits of their choice, interests, social and religious needs, either in a group or on a one to one basis. The local vicar holds Church of England services on each Friday morning in the homes’ chapel and the Roman Catholic Priest visits fortnightly. The chapel is inter-denominational and is available to everyone. One resident said the activity opportunities within the home were great and the activity coordinator is always enthusiastic and open to ideas, which he will always endeavour to pursue. Resident feedback, in previous inspections, with regard to activities in the home has consistently been positive and on each inspection the inspector has observed the residents participating in the preparation of a themed event, on this occasion they were considering planning a murder mystery. The manager indicated that consultation with residents and the cook was currently taking place to review certain areas of the menus following feedback from resident questionnaires. Discussion took place with regard to including a dietician to advise on specialist diets, particularly diabetics. Residents who spoke about the food described it as good although one resident with diet and tablet controlled diabetes indicated choice with regard to deserts was limited and conflicting information with regard to diet was confusing. Meals were observed to be of good proportion, nutritious and well balanced. The choice for the day was salmon in white wine and dill sauce or chicken curry. Assistance was given with dignity and patience. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) Service users retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicines. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 & 21 Staff engaged positively with the service users and demonstrated a good understanding of the residents they were supporting, respecting their privacy and dignity. Medication was managed appropriately. EVIDENCE: Staff were observed to be respectful and helpful in their approach to the residents and were accessible to the residents at all times throughout the inspection. Residents spoken with said the staff were kind and helpful. Residents are looked after well in respect of their health and personal care needs. Further attention needs to be given to include emotional and psychological needs within the care planning process. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 15 Care plans examined were well-structured utilising risk assessments associated with dependency level; mobility, continence, nutrition and skin viability. Although the corporate risk assessment forms had been altered to allow for more information to be recorded, in some cases there was still not enough space for clear detailed related care planning arrangements and guidance for care staff in managing or reducing the identified risk. In the care plans viewed, physical healthcare needs requiring nursing management and intervention were comprehensively documented, particularly pressure sore prevention and management and wound care. The home demonstrated close working relationships with the Primary Healthcare team, including evidence of guidance and prompt intervention from healthcare professionals and support organisations. Attendance to the diabetic clinic for a resident newly diagnosed with type two diabetes was evident although advice and treatment was not fully reflected within the care plan to enable care staff to continue to provide relevant and consistent support, particularly with regard to dietary needs. There was scope for developing a more person centred holistic approach to care planning, with greater focus on emotional needs and maintaining strengths. Whilst care plan objectives covered personal and healthcare needs, those examined did not reflect emotional needs and provide essential information for care staff to know and understand each individual particularly those who may be experiencing varying psychological effects from a chronic disease process and how these may impact on well being. One resident described ‘up and down days’ and ‘the difficulties in accepting’ the sudden enormous changes in lifestyle in relation to the loss of mobility and deteriorating eyesight contributing to a reduced level of independence and the implications of diabetes and having a ‘sweet tooth’. This individuals care plan did not reflect the underlying emotional needs discussed or the support required promoting or maintaining optimum independence or quality of life. All of the files sampled held pro forma statements consenting to the administration of medication by care staff. The pro forma did not provide adequate assessment information determining considered decisions taken or alternative strategies to care staff assuming control of medication. The care plans identified medication prescribed, however information relating to the side effects and adverse reactions of medicines being taken by individuals was not readily available. Registered nurses administered medication, based upon the sample of records inspected the receipt, administration, storage, security and disposal of medication was found to meet National Minimum Standards. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 16 From conversations with staff it was evident that they responded appropriately to the changing needs of the residents and provided all the care and support they were able. In a letter of condolence for the recent death of resident, compliments were expressed by the local Huntingdon Chorea Society for the high standard of care Seven Rivers have consistently provided over the years. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home demonstrated a low awareness of the Essex local guidelines and appropriate procedure to be followed in the case of an alleged abuse, which may potentially place a service user at risk. EVIDENCE: Records showed that staff had received training from Leonard Cheshire on issues relating to the protection of vulnerable adults. A recent situation at the home has highlighted the need for the home to ensure a more robust approach to following Local policy guidelines in the event of an allegation of abuse; to ensure a structured strategy is agreed and followed and the appropriate body take the lead in a POVA investigation, and to ensure a satisfactory and conclusive outcome. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The home created a comfortable and homely ambience and areas seen were cleaned to a high standard. EVIDENCE: In general, the home is well maintained and suited to residents’ needs. A programme of routine maintenance to buildings and redecoration of the premises was seen to have continued since the last inspection. Re decoration to the dining room was noted and some residents had participated in the process of choice and purchasing of the soft furnishings. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 19 Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 & 36 Staff training is provided in a planned way to ensure mandatory requirements are met. The service had not yet achieved an adequate proportion of carers having attained an NVQ qualification in care at level 2 to ensure a competent staff team to support the residents. Residents do not benefit from staff trained in specialised areas pertinent to their needs. A stronger emphasis on formal recorded supervisions is required to enable staff to reflect and develop own practice and have a stronger link to care practice issues. EVIDENCE: Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 21 The home has a new training coordinator in post and the staff training and development matrix is currently being updated to identify specific mandatory training received or required. The matrix and information provided in the pre inspection questionnaire identified that the previously reported in excess of 50 target of achievement of carers having attained an NVQ qualification in care at level 2, was not correct. At the time of inspection, the service had not yet achieved an adequate proportion of carers having attained a NVQ 2, or a date by which this will be achieved. Fourteen out of thirty two care staff and three bank staff had successfully attained NVQ 2. The inspection highlighted a training need for care staff in awareness and understanding of the psychological stages of loss and grief to enable appropriate emotional support to be delivered. It was noted that the Senior Nurse had recently undertaken training in Palliative Care. All new care staff received an induction; discussion took place with regard to the introduction in 2006, Skills for Care, Common Induction and Foundation Standards and their integration within the Leonard Cheshire Induction. Progress has been made with formal individual recorded supervisions, however these need to be more frequent and fully documented to reflect all the elements necessary to support staff in developing and sustaining their working practice. The sample of staff files examined did not contain a record of regular supervisions and records of formal one to one meetings indicated a need for discussions to have a stronger link to care practice issues and meeting the needs and objectives of the individual service users. . Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Quality assurance and monitoring systems were not fully in place to meet NMS. However the home had begun to address quality monitoring by the implementation of service user questionnaires but further development is required to measure service and care outcomes and inform future practice. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 23 EVIDENCE: Since the previous inspection the Registered Manager had progressed in addressing quality monitoring by the implementation of resident surveys. The surveys looked at resident participation and consultation, house keeping and social activities. The results identified consultation with regard to the care planning process and menu planning as areas for improvement and the home was currently exploring ways to improve practice and achieve outcomes for residents. The continued progress of quality assurance will be looked at in the inspection process. . Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 X 38 X 39 2 40 X 41 X 42 X 43 X 2 3 X X X LIFESTYLES Standard No Score 11 4 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Seven Rivers Cheshire Home Score 3 2 3 3 DS0000015362.V284626.R01.S.doc Version 5.1 Page 25 yes Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 01/05/06 YA6YA19OP 15, 14, 7 2. YA23 13, 21 3. YA32 18 4. YA35YA17 18 The Registered Manager must ensure individual care plans reflect all assessed needs including emotional and psychological health needs and detail all information required for care staff to give appropriate support and consistency.Previous requirement not met within given timescale October 2005.. The Registered Manager must 01/04/06 ensure robust procedures and Local guidelines are followed in the circumstances of an alleged abuse. The Registered Manager must 01/06/06 ensure staff have the competencies nd qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets. The Registered Manager must 01/07/06 ensure that training and development are linked to the homes’ service aims and to individual plans particularly with regard to emotional needs and DS0000015362.V284626.R01.S.doc Version 5.1 Seven Rivers Cheshire Home Page 26 5. YA36 12,18 6. YA39 24 diabetes. The Registered Manager must 01/05/06 ensure staff receive regular, recorded covering all elements of the supervision process. The Registered Manager must 01/07/06 continue to develop an effective quality assurance and monitoring system to measure the homes success in achieving the homes aims and objectives, meet individuals needs and inform practice. Previous requirement not met within given timescale. 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 YA1OP1 Good Practice Recommendations The Statement of Purpose, Service Users Guide and other information about the home should be made available in alternative formats; this particularly refers to large print for the visually impaired. Dietetic advice and guidance should be sought for the provision of special therapeutic diets to ensure consistency and choice. 2. OP15YA17 Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. Seven Rivers Cheshire Home DS0000015362.V284626.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!