Inspection on 14/12/07 for The Chase

This inspection was carried out on 14th December 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

The Chase 08/12/08

The Chase 07/06/07

The Chase 04/01/07

The Chase 23/05/06

The Chase 10/11/05

The Chase 06/05/05

The Chase 11/10/04

The Chase 27/04/04

The Chase 09/02/04

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

CARE HOMES FOR OLDER PEOPLE The Chase 53 Ethelbert Road Canterbury Kent CT1 3NH Lead Inspector Chris Woolf Key Unannounced Inspection 14th December 2007 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 The Chase DS0000057129.V356673.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. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chase Address 53 Ethelbert Road Canterbury Kent CT1 3NH 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) 01227 453483 01227 463483 Charing Healthcare Post Vacant Care Home 31 Category(ies) of Dementia - over 65 years of age (31) registration, with number of places The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Admissions from 9 February 2004 to be restricted to clients over 65 years of age in the registered category DE (E). 7th June 2007 Date of last inspection Brief Description of the Service: The Chase is a 2-story building consisting of an original house with a more recent extension. It is owned by Charing Healthcare but the providers name is changing to Pure Lake and the responsible individual is changing. The home is registered to provide care for up to 31 older people, most of who have dementia. There is a condition on the registration restricting admission to clients over 65 years of age with Dementia. The home is located about twenty minutes walk from the busy city of Canterbury. It is almost directly opposite the Kent & Canterbury hospital and is on a direct bus link. There is on site parking for up to six vehicles and on street parking which is restricted to 4 hours between 8-4 Mondays to Fridays. The current fees for the service at the time of the visit range from £377.27 to £400 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address for the service is terry.wall@charinghealthcare.co.uk. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information used in this report has been gained from the following sources. An Annual Quality Assurance Assessment (AQAA) completed by the service. Questionnaires completed by 1 service user, 5 relatives, and 4 members of staff. And a site visit to the home that lasted 8 hours 5 minutes. The site visit was unannounced. This means that neither the staff nor the service users knew that it was going to take place. During the site visit we had a tour of the building. We talked briefly with a number of service users. Discussions were held with 3 visitors, 5 members of staff, and the acting manager. Observations were made of the well being of service users, the interactions between staff and service users, a meal being served, and medication being administered. A selection of records were inspected including care plans, staff recruitment files, quality assurance records, and a variety of safety records. The term ‘acting manager’ used in the report refers to the person that the providers have appointed to be in charge of the day-to-day running of the home. At present the post of ‘Registered Manager’ is vacant. What the service does well: There is a friendly and welcoming atmosphere in the home and visitors and staff confirmed this. The new care plans that have been completed are comprehensive, person centred, and include a lot of small details that are important to the individual service user. The interaction between staff and service users is positive. Visitors are made to feel welcome in the home. The acting manager is supportive of service users, visitors and staff. A visitor comment card included, ‘I am pleased that my mother is living at The Chase’. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although the odour problems in the home have been improved there are still some areas that need additional attention. Service users’ bedroom doors need to be fitted with locks and the service users should be offered a key for their own room. The provider needs to produce a programme of decorating and refurbishment, together with timescales and submit this to the Commission. It is important that mandatory training is up to date for all staff The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 7 Staff supervisions are not yet all being done 6 times a year. Fire Tests must be carried out weekly. 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. The Chase DS0000057129.V356673.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 The Chase DS0000057129.V356673.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): 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs are assessed by the home and admission will only be arranged if the home is confident of meeting their needs. EVIDENCE: The home has recently updated their Statement of Purpose and Service User Guide to take into account recent changes in the provider and management structure of the home. A copy of these documents is given to all prospective service users and is also available in the home. A document ‘Welcome to The Chase’ which includes the room number and details of what is on offer in the The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 10 home is placed in bedrooms ready for the admission of any prospective new service user, a copy of this document is also given to families. Each service user is issued with and signs a contract/statement of terms and conditions with the home. It is recommended that contracts are updated, as they should include details of the amount of fee payable and by whom. There was a requirement on the last report that pre-admission assessments must be improved to ensure they are holistic and supply sufficient information on which to base a care plan. The acting manager is currently using the same format for assessment but is including far more detailed written information on the form. She visits all potential service users either in their own home or in hospital to carry out a comprehensive assessment of their needs prior to any arrangements being made for admission to the home. In addition to the prospective service users physical, mental and social needs, the assessment also takes into account any religious, cultural or other equality and diversity needs they may have. The home will only accept a new service user if they are confident of meeting their needs. Visitor comment cards confirm that the home meets the needs of the service users. One comment card included the statement, ‘I think its difficult to always determine the needs of someone with Alzheimer’s. They keep my mum warm, safe and properly fed, and clean and dressed and when they have time they give her company and affection’. The first month of any service users occupancy is treated as a trial period. This home does not offer the facility of intermediate care, which is a specialised service of intensive rehabilitation to enable service users to return to their own home’s. The Chase DS0000057129.V356673.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, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health care needs are being met by the home supported by a multi-disciplinary health care team. They are treated with dignity and their right to privacy is maintained. EVIDENCE: A comprehensive plan of care is provided for service users based on their preadmission assessment and regularly updated to reflect changes in need. The acting manager is updating all care plans as required on the last report to ensure that they are comprehensive and person centred. This work is very time consuming and although the acting manager is doing a good job of the updating she has not yet quite completed the task. Therefore a The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 12 recommendation is made that this work continues to ensure that all care plans are updated to the new standard to promote person centred care. Care plans include the physical and mental needs of the service user, their life history, likes and dislikes, religious and cultural needs, and their wishes around death. There are a variety of individual risk assessments in each care plan including falls risk, nutritional assessment, tissue viability assessment and where required assessments for the use of bed rails and bumpers. Weights are recorded monthly and the home has a set of sit on scales to help monitor the weights of less mobile clients. The new care plans are very detailed and include small but significant facts such as how many sugars a person likes in their tea, and in some cases a photograph of how the service user likes their hair. These small details are so important to maintain the ‘personality’ of the service user. The home is now involving the service user and/or their relatives in the compiling and review of care plans as required on the last report. One relative comment card included the statement, ‘Her care plan is a good one’. There was a requirement on last report about fully meeting health care needs. These needs are now being met by the home supported by a multi-disciplinary health care team. Evidence was seen in care plans of contact with doctors, nurses, optician, chiropodist, physiotherapist, diabetic nurses, care manager, continence advisor, hospital visits, anticoagulant clinic, solicitor, dentist, and aroma therapist. The visiting opticians also do hearing tests and have offered to do a training course on sight problems. Visitors commented, “The care is much better than it was”, and “She has the chiropodist”. A visitor comment card included, ‘All needs well done’. Relatives are kept informed of events that have an effect on service users lives. One visitor commented, “The ask me if its O.K.”, and a visitor comment card included, ‘I feel that any questions I ask are answered in a straightforward manner and suggestions and advice are offered’. Medication policies and procedures have been improved as required in the last report and are now of a satisfactory standard. The acting manager carries out regular audits of the medication to ensure that the standard is adhered to and recently there was a regulation 26 visit specifically to audit the medication. Only staff who have received medication training administer medication to service users. Service users are treated with respect by the staff team and their right to privacy is maintained. One staff member commented, “It’s a lot better”. Relative comment cards included, ‘She is very difficult and yet the staff always have an excellent manner with her. Lots of good humour’ and ‘their staff are very caring and affectionate towards the people in their care. They make a genuine effort to understand their likes and dislikes, and they recognise that they are all individuals’. . The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 13 The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 14 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, 1, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to make choices about their life style; they are supported to maintain contact with family and friends; and they receive a balanced diet. EVIDENCE: Activities in the home have been increased in line with dementia care needs as required on the last report. The recording of activities, service users interests, and 1:1 interactions has improved. A staff member said, “Every day a member of staff is assigned to activities”. Records seen indicate that activities are varied and include such things as 1:1’s, painting, manicures, reminiscence, walks in the garden, and dancing. Service users said, “I like to join in”, and “Teddy is joining in today”. When service users wish to help they are The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 15 encouraged to do small tasks in the home such as folding tea towels, laying tables, and breaking up boxes. A service user said, “I am going to help lay the tables”. A variety of entertainers visit the home. On the day of the site visit ‘Music for Health’ were present and service users were seen to be enjoying singing along and shaking tambourines and maracas. A relative comment card included, ‘My mother is not the easiest of residents but staff continue to try and stimulate her interests and include her in social events etc’. The acting manager confirmed that the home is planning to further increase the activities on offer. The new provider has a mini bus that is shared between her home’s and The Chase is currently planning outings for 2008. Service users’ religious needs are supported by the home. The acting manager confirmed that a vicar calls regularly and visits those who wish to see him in their own rooms. Other denominations are welcomed into the home and arrangements are made for service users to follow their own religion when requested. Visitors are made welcome in the home and there are no restrictions on visiting times. A visitor comment card included, ‘… the staff are really friendly - they certainly support us, her daughters’. Service users are encouraged to make choices in all aspects of their daily lives. A visitor comment card included, ‘From what I have seen they do their best to allow people to make their own choices’. Residents are given a balanced diet. There are choices at all meals and further options if they do not like the choices on offer. Service users commented, “I had cornflakes and toast for breakfast”, “I like my food”, and “lunch was nice”. The cook explained that most main courses are cooked fresh and that a variety of fresh and frozen vegetables are used. Staff commented, “The meals are O.K., they have choice”, and “Meals are good”. A meeting is planned with the acting manager and the cook to review and update the menu. The cook confirmed that she does not use salt in the cooking but that service users can add their own if they wish. The home has recently changed their main food supplier and this would appear to be a change for the better. There is one service user whose son brings her in a meal from his restaurant daily but the cook still tries to tempt her with other foods that she enjoys. Visitor comment cards included, ‘They have sorted out her dietary needs’, and ‘I wish more meals were cooked from scratch with fresh ingredients. There seems to be too much processed food’. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their families know that their concerns and complaints will be listened to and acted on. Service users are protected from abuse. EVIDENCE: The home has a clear and accessible complaints procedure and service users’ representatives confirmed in their comment cards that they know how to make a complaint if necessary. One card included, ‘when I speak to the manager about a situation action is taken straight away to resolve the issue’. There have been no complaints raised with the home or the Commission since the last inspection. Visitors spoken to on the day of the site visit said, “We are having a problem with clothes but it has improved. …. I’m fed up with buying socks and pop socks”, and “If I speak to Teri it normally happens”. At the time of the last inspection there was an open Adult Protection alert on the home and this has since been lifted. Almost all of the staff have now attended training in the Protection of Vulnerable Adults. No new member of staff is employed until a satisfactory check of the Protection of Vulnerable The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 17 Adults register has been received. Staff spoken to on the day of the site visit all confirmed that they would know what to do it they suspected abuse was taking place. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 18 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, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable home with rooms personalised to meet their needs but some outstanding maintenance and odour problems mean service users’ needs are not being fully met. EVIDENCE: Since the last inspection several requirements regarding the environment have been met. The work to make the ‘hidden’ bathroom into a wet room is almost complete. Several bedrooms have been decorated and more decoration is The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 19 planned. New flooring has been laid in one of the bathrooms. The Staff toilet has been decorated. However there are still some areas of maintenance outstanding, including the replacement of a chipped bath, decoration of one of the downstairs bathrooms, and decoration of additional bedrooms. A requirement has been made that the provider must submit a programme to the Commission of the outstanding refurbishment and decorating, with timescales of when the work is to be completed. There was a requirement on the last report that fire doors should not be wedged but must be fitted with appropriate self-closing mechanisms and this has now been done. The garden area is tidy and nicely planted. Part of the front is block paved to provide a parking area and the remainder of the front has been provided as a secure garden area. A visitor commented, “The garden always looks nice”. The home has a variety of communal areas allowing service users choice of where to sit, where to have their meals, and giving them the opportunity to choose whether to join in communal activities or not. The communal areas are appropriately decorated and have comfortable seating. A service user said, “It’s nice and warm here”. Service users’ bedrooms are personalised to meet their needs. A visitor said, “Mums room has been changed round so she can’t fall out of bed”. Where rooms are shared curtains are provided to maintain privacy for personal care tasks. One visitor whose relative shares a room commented, “ We have asked for another room and they have said they will move her”. This was discussed with the acting manager who confirmed that she in turn has spoken to the new provider and that a move to a single room is going to be arranged. There was a requirement on the last report regarding call bells, suitable locks, lockable drawers, and seating and furniture in bedrooms. The majority of this requirement has now been met although the doors have not yet been fitted with suitable locks. The ‘acting manager’ is advised to seek the advice of the fire officer as to what locks he considers suitable and the requirement regarding this is repeated. Appropriate infection control measures are in place in the home and alcohol hand cleansing gel has been sited in a variety of areas. Cleanliness in the home is adequate but could be improved. Visitors commented, “Mums toilet is always dirty and the window ledges are not cleaned properly”, and “Its much cleaner now”. There has been a requirement on the last four inspection reports that all areas of the home must be kept clean and free from offensive odours at all times. Although the situation has improved greatly, there are still 4 bedrooms where an unpleasant odour persists. The acting manager confirmed that the carpets have all been cleaned and that some have been replaced but that the odour is still there. The requirement is repeated and the home is urged to investigate every possible avenue to eradicate these The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 20 unacceptable odours. Visitors commented, “The odour is not here now”, and “The smell has improved”. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. A team of staff who have been properly recruited care for Service users. Additional staff training is needed to ensure service users are fully protected. EVIDENCE: There was a requirement on last report that there must be 3 members of night staff on duty each night and this has now been met. The staff rotas indicate that there is sufficient staff on duty to meet the needs of the service users. A member of staff commented, “There is enough staff on duty”. The home currently has 43 of the care staff trained to NVQ Level 2 or above. Two more staff are intending to do this training and there are currently 6 overseas nurses employed who are not included in the NVQ figures. Staff commented, ”I have just done NVQ 2”, “I have got NVQ 3”, and “I am a trained nurse in Ghana”. A recommendation has been added that the home The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 22 continue with N VQ training to ensure a minimum of 50 trained to Level 2 or above. Recruitment procedures in the home are sound. No new member of staff is employed until 2 satisfactory references and a satisfactory check of the POVA register has been received. Appropriate checks are made on foreign staff to ensure that they are eligible to work in this country. Staff files need to be updated to meet the requirements of the current Schedule 2 and a recommendation is made about this. There was a requirement on the last report that all staff must be trained in the mandatory subjects plus dementia and adult protection. Although a lot of training has been undertaken in the last six months there are still quite a few gaps in the training matrix, particularly for some of the mandatory subjects and therefore this requirement is repeated. Staff comments about training included, “After Christmas I am going to do an Insulin course”, “We have a hoist for moving and handling and are trained to use it”, and “I enjoyed the Dementia training and would now like more in depth training, its important to understand how they are feeling”. This was discussed with the acting manager who confirmed that the staff will be doing a 3 day dementia course in 2008. A coursed on sight problems is also being arranged. Visitor comment cards about staff training included, ‘Training matrix for staff seen’, and ‘They do seem to know what they are doing but I would be reassured if I knew they had their skills updated regularly’ General comments about staff included visitors who said, “Some staff are very good but the foreign staff tend to keep themselves to themselves more”, and “The Girls work hard”. A service user commented, “The staff look after me”. Staff comments included, “It’s a good team here”, “Communication between staff is not always brilliant”, and “We have got a stable staff team now”. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being managed in a way that is supportive of service users but it is important that a ‘Registered’ Manager is appointed. The Health, Safety and Welfare of Service users could be compromised through a lack of fire safety checks. EVIDENCE: A person appointed by the providers to act as manager is currently running the home. She has now been in post for just over 6 months and this has been a The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 24 traumatic time as there were a considerable number of problems to sort out. She is now getting to grips with the home and has worked hard to reduce the number of requirements made on this report. She now feels she is ready to submit her application to the Commission to apply to become the Registered Manager of the home. A recommendation has been made regarding this. There have been a lot of very positive comments about the acting manager. A relative comment card stated, ‘Co-ordination between staff and manager has improved immensely to how it used to be’. Visitors commented, “Teri is very good”, and “Teri has done a hell of a lot”. Staff comments included, “If I say anything to Teri she gets it done straight away”, “Teri is good with the clients and they love her”, and “Teri gives a lot of support, she is always prepared to listen and help in any way”. There have also been changes in the senior management of the service recently. Although the changes do not constitute a new service the responsible individual is changing and it is proposed that the name of the home ownership be changed from Charing to Pure Lake. The new provider has already had an open day with service users families and has spoken with staff. One member of staff said, “The new owner seems very nice. She comes in and chats, I’m optimistic’. The atmosphere in the home has improved under the new ‘acting manager’. Visitors commented, “The atmosphere is much better”, and “The atmosphere has improved”. Staff said, “The atmosphere is much better”, and “It’s a good atmosphere, absolutely brilliant”. The home’s quality assurance includes questionnaires to staff and residents and is being expanded to include families. A survey on activities is about to be circulated. An analysis of the last questionnaires has been produced and is available for inspection in the home. The manager has an Audit tool that she uses and audits include Care Plans, Service Users allowances, training matrix, medications, and accidents. The home looks after some ‘pocket monies’ for clients. All transactions are clearly recorded, monies are kept in separate packets, receipts are kept, and families sign the transaction sheet. There was a requirement on the last report that all care staff must receive formal supervision at least 6 times a year and all other staff should be supervised on a continuous basis as part of the normal management process. Although the acting manager has made a start on these supervisions there is not yet sufficient evidence to prove that they will be carried out at the prescribed frequency and therefore a recommendation is made about this. In general the health, safety and welfare of staff and service users is protected. Staff training in the mandatory health & safety subjects is not quite The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 25 up to date but is ongoing and has improved over the year. Safety testing of equipment and appliances is up to date. A new fire system has bee installed. However, the last weekly test of the fire alarms was 03/09/07. Although the manager explained why this testing had not been carried out fire safety is very important and such a lapse is unacceptable and therefore a requirement has been made about this. The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 2 X 1 The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 (2) (b, c & d) Requirement The provider must submit a programme to the Commission of the outstanding refurbishment and decorating, with timescales of when the work is to be completed. (Previous requirement on maintenance timescale 1/12/07 partially met) The manager should consult with the fire officer and must ensure that all bedroom doors are fitted with suitable locks and service users are offered a key for their own room. (Part of a previous requirement. Timescale of 01/08/07 partially met) All areas of the home must be kept clean and free from offensive odours at all times (Outstanding requirement from last four inspections. Timescale 01/09/07 partially met) All staff must be trained and up to date in the mandatory subjects (Part of a previous DS0000057129.V356673.R01.S.doc Timescale for action 31/03/08 2. OP24 23 (2) (a & n) & (5) 31/03/08 3 OP26 23(2)(d) 31/03/08 4 OP30 18 (1) (c) (i) 30/05/08 The Chase Version 5.2 Page 28 5. OP38 23 (4) (c) (v) requirement. Timescale of 01/09/07 not quite met) The fire alarm call bell system must be checked every week. 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP2 OP7 OP28 OP29 OP31 Good Practice Recommendations Service users contracts/statements of terms and conditions with the home should be updated to include details of the amount of fee payable and by whom. The acting manager should ensure that the remainder of the care plans are updated to the same standard as those already completed to promote person centred care. The home should continue with N VQ training to ensure a minimum of 50 trained to Level 2 or above. Staff files should be updated to meet the requirements of the current Schedule 2 of the Care Home’s Regulations. The acting manager should submit her application for the post of ‘Registered Manager’ without further delay to ensure continuity of care, and stability for the service users. All care staff must receive formal supervision at least 6 times a year and all other staff should be supervised on a continuous basis as part of the normal management process. 6. OP36 The Chase DS0000057129.V356673.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Chase DS0000057129.V356673.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. 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. 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