Inspection on 29/07/08 for The Chimes

This inspection was carried out on 29th 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

The Chimes 14/08/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 The Chimes 25 Grosvenor Road Paignton Devon TQ4 5AZ Lead Inspector Clare Medlock Key Unannounced Inspection 29th July 2008 09:30 The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 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 Chimes DS0000070223.V368733.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 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. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chimes Address 25 Grosvenor Road Paignton Devon TQ4 5AZ 01803 559205 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) Diamond Care (2000) Limited Mrs Karen Barnes Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places The Chimes DS0000070223.V368733.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: Learning disability (Code LD) Learning Disability (Code LD(E) The maximum number of service users who can be accommodated is 10. 14th August 2007 2. Date of last inspection Brief Description of the Service: The Chimes is registered to provide accommodation and care for a maximum of ten people who have learning disabilities. Both younger adults and people over sixty-five years of age can be accommodated. The Chimes is situated in a residential area of Paignton and is within walking distance of the town centre, bus and train stations. The sea front is less than one mile away. Accommodation is provided over two floors with stairs between. On the ground floor are a kitchen, dining room and lounge. On the first floor is a laundry room. There is parking space at the front of the building and a small garden with patio at the rear. This has different levels making wheelchair access difficult. Information about the service is made available in a Statement of Purpose and in Service Users Guides. Copies of these documents are available on request or can be viewed at the Home. Inspection reports are made accessible to service users and visitors at the home. There was an error which meant the last inspection report was unavailable on the CSCI Website. This is not a reflection on The Chimes. The weekly fees currently range from roughly £370 to £1000 and vary greatly according to the amount of support each person needs. The Service Users’ Guide states that this includes all care support costs, accommodation, food and drink, heating, lighting, laundry, staff services and annual holidays. The home has recently is registered under the company name of Diamond Care (2000) Limited. The Chimes DS0000070223.V368733.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 inspection was unannounced and took place on Tuesday 29th July 2008. Prior to the inspection the Manager was sent an AQAA (Annual quality assurance assessment). This document provides us with an overview of what is happening in the home. It tells us about staffing levels, any recent complaints, fees, and information about general maintenance and policies within the home. Before the inspection we also sent out questionnaires to people who use the service and their family and friends. We received six surveys from people who use the service and two surveys from relatives. This information gives us a picture of what life is like at the home and helps to focus on what we need to look at during our inspection. At the inspection we ‘case tracked’ two people who use the service. This means we looked in detail at the care three people receive. We spoke to staff about their care, looked at records that related to them, spoke with them and made observations if they were unable to speak to us. We also spoke to three other people at the home. During the inspection we spoke with the Manager and two care staff. We spoke with five people who use the service. We also observed interactions between staff and people who use the service. We also looked around the home, inspected medicine records, three staff files and other records. What the service does well: People say they like living at the Chimes. The Chimes is clean, comfortable and homely. It is close to the town centre. Bus and train stations are nearby. People who live at the Chimes are helped to get the things they need and do what they want. Staff know how to help people to do this. The Manager and staff are good at helping people to make decisions about how they want to spend their time. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 6 People are protected from abuse. They know they can talk with the staff and Manager if they have any worries. The Manager makes sure that staff give a good, safe service to people who live at the Chimes. The Manager knows how to manage the Chimes properly and thinks of ways to improve it. The Chimes is a safe place for people to live. What has improved since the last inspection? What they could do better: The information provided to people and their families should be check to ensure all details are accurate and up to date. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 7 The way complaints are recorded should change to ensure the manager has an overview of all complaints, concerns and allegations. This will be useful to show any trends that occur and will show an how complaints have been managed. The manager should also improve the way pre employment checks are recorded. The level of CRB (Criminal record bureau-police check) check should be recorded before it is destroyed and the record should show whether a POVA (Protection of Vulnerable adults) check has been included. This will show that staff have had all pre employment checks performed. 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 Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are systems in place to make sure the home are able to decide whether they can meet the person’s needs before they are admitted. Minor changes to the documents provided to people would mean that people would be given up to date information EVIDENCE: Surveys completed by people who use the service showed us that they had been asked if they wanted to move into the home and that they had enough information to decide if it was the right place for them. One comment included “I asked my mum if they did not mind me coming to have a look”. The manager said that the last admission to the home was recently for a brief period of respite. This person had been to the home before, so already knew a lot about it. Care plans showed that the manager had obtained sufficient information on the person before they came to the home. The manager told us that referral to the home is usually through social services. The person who wishes to move to the home and their family then The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 10 have an opportunity to meet other people who live at the home. A copy of the Service Users’ guide is given (which contains pictures). The person is then offered to join other residents for a meal. The manager then completes a formal written assessment. She gathers the information from the visit, the person himself or herself, care managers, health care professionals and relatives of the person. There is then a three months trial visit. This information is documented in the contract and then stored in the persons file. A Statement of Purpose was available. This has been updated to include changes in the ownership and contact details. Minor changes are now needed to update the change in Commission for Social Care Inspection details. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are included in making decisions about their own lives. They take part in planning the care and support they receive. EVIDENCE: People who use the service told us they were able to chose what they did each day, in the evenings and at weekends. Each of the people we spoke with each described different activities they do each day. During the inspection one person had decided to go out with staff but half way through the trip had changed their mind and come home. Surveys received from people who use the service also confirmed people are able to make decisions about what they do each day. Comments included: ‘Yes, Sometimes we do this as a group’. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 12 Activity programmes are displayed on the wall and within care plans. Some records showed that people who use the service can choose to help with the cooking or other domestic chores in the home. Individual care plans clearly show whether these are part of each person’s individual goals. Staff told us people who use the service also participate in other ways that the home is run. An example was given of staff being interviewed by people who use the service. Individual service user plans were well constructed and were person centred but written in a way that was clear to follow. Plans clearly showed how care should be given to each person in a safe way. Behaviour patterns were explained and records kept to monitor these. Risk assessments have been improved at the home, to show that people who use the service are able to take appropriate risks in order to develop their skills, autonomy and independence to enable them to reach their full potential. Staff told us they were aware of the need to keep information confidential. Staff are expected to sign an agreement that they will do this. The subject of confidentiality is also discussed at induction. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The people living at the Chimes enjoy full and active social lives and interact well with each other and with the manager and staff. EVIDENCE: The people at The Chimes lead active social lives. An activity programme and social calendar show the many and varied activities that are arranged and what number of staff support hours are provided as part of the contractual agreement. Several people attend day care services, which offer a range of social activities including outdoor pursuits, crafts and drama. Within the home people have access to crafts, games, pool table, TV, DVD and computer games (Wii). A member of staff had recently donated a computer which one person explained The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 14 was used to download the photographs she takes. Another person showed us a favourite passtime of making complex and spectacular patterns with felt tip pens, and other people at the home told of a recent group trip to a music concert. People who use the service told us they were very excited about the ‘beach party’ that was being held at their local social club that evening. The manager told us that some people also attend a local church and have access to social events held there. During the inspection some people were attending events put on as part of the local festival. Surveys from people who use the service confirmed that people in the home are able to go out. Comments we received read ‘I go out a lot’ and ‘I am independent’. Relative surveys also told us that staff at the home encourage people who use the service to join in and try new activities. Comments included ‘The care home is very good with her. They try and motivate her into doing things of interest. She likes being out, but just shopping or coffee shops. They are trying to get outside interests for her i.e. day centres so she can meet other people and find a new interest’ and ‘She is kept entertained and busy and has a range of non-Chimes based activities.’ Some of the people in the home need staff support to go out. A large car is used for this purpose. Some of the people who use the service enjoy being actively involved in the day to day running of their home and are actively involved in household duties such as cleaning and ironing, although some people need more support and encouragement to participate. Care Plans show how this is done and what stage the person is at in achieving the goals. People who use the service are actively involved in formal meal planning, which is only carried out for the main meal of the day. People are routinely able to choose what to eat for breakfast and lunch and this is recognised as good practice. The registered manager explained that specific health related diets are catered for and gave examples of how these needs are being met. Staff support and encourage people in the home to maintain links with their family. Comments on a relative survey read ‘she phones us quite often and is assisted in this by the Chimes staff. We also get cards and letters’. Another comment read ‘We visit the Chimes weekly/fortnightly. Staying for approx one hour. We are made very welcome and join our daughter and other residents and staff in the lounge. Much information is gained through the course of informal conversation’. The manager explained that family have been invited to attend a group holiday where appropriate to help the person have a family holiday with their parents, whilst being supported by care staff. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 15 Holiday photos were displayed in the dining room of the recent holiday abroad. People who use the service appeared very in these photographs. The manager explained that this holiday abroad was included within the fee, and an additional planned holiday to Butlins is extra if people choose to come. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. 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. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will receive the care they need and that their mental and physical health will be carefully monitored. Medicines are well managed at the home. EVIDENCE: People who live at the home looked fit and healthy. Relative surveys said they thought the care at The Chimes was very good and that they are involved in the health care needs as appropriate. Comments included ‘I am informed when she goes to the doctors and they always tell me the results’ and ‘We are informed about doctors and psychiatric appointments and are even invited to attend some’. Relatives also said ‘Her diet has been monitored- we feel that she is eating a health diet and has lost her excess weight.’ Relatives were asked Does the care home or agency give the support or care to your relative/ friend that you expect or agreed? One comment we received read ‘Hygiene- regular baths, The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 17 clothes and laundry OK-always seems well groomed. New pulse alarm being used under pillows to monitor fits’. Another comment from a relative read ‘We are more than satisfied with all at the Chimes. She can be a handful at times but they have coped and are coping with her very well. With the right approach (firm but kind) and tweaking of medication, things have improved over the last couple of years. Care Plans have been changed to show that the persons health is being monitored and that timely referrals are made with the primary and secondary healthcare services as and when necessary, subject to the wishes and needs of people who use the service. People at the home are given the help they need to attend medical appointments and encouragement if they are reluctant or refuse to see their GP. Agency variety of health monitoring forms are kept depending on the needs of the people in the home, with plans showing how health care needs are to be met. Examples of these included weight charts, and weight reducing and increasing diet plans. Medicines are well managed at the home. Staff who are responsible for administering medicines told us they had received training from the pharmacist who supplies the home. The manager explained that the pharmacist has supplied staff with new training booklets they have introduced. Storage facilities were adequate at the home. The manager explained that no one at present was able to self medicate but the planned programme to introduce lockable cupboards into each persons room would help prepare people for this process. The manager told us that there were no controlled drugs at the home and no medication that required refrigeration. Policies regarding homely policies were available and MAR (Medicine administration records) were well completed. Records were also available for the receipt and return of medications. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Although complaints are well managed at the home, documentation needs improving to show that the home see complaints and niggles as a quality assurance process. People are protected from abuse by the homes policies, procedures and ongoing training provision for the staff and manager. EVIDENCE: Feedback from questionnaires indicated that they would know what to do if they needed to make a complaint about the service provided. All of the surveys said that they would feel comfortable making a complaint to the manager, a member of staff or their family. One comment read ‘If I am not happy with something I will let staff know’ another said they would speak with ‘Karen (the manager), my key worker, or my mum’. Relatives also supported this view and said ‘Chimes has always responded if necessary’ and ‘There have only been minor concerns, athletes foot and dentist’. The Manager discussed a recent complaint she had sent to the head office to investigate. The findings are being collated at present but have been investigated appropriately within agreed timescales. The Commission for Social The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 19 Care Inspection has also received a formal complaint, which was being dealt with at the time of this report being written. People we spoke with said they felt safe at the home and liked the manager and staff very much. Staff told us they would not hesitate if they witnessed any abuse occurring in the home. Staff were aware of how to report abuse in the absence of the manager and Provider. All staff, including the manager, had attended training in the protection of vulnerable adults (POVA). This training has been provided by Devon County Council and is evidence of good practice and provided staff with local guidance as agreed by a multi agency safeguarding team. The manager was aware of how to correctly report allegations and was supplied with updated telephone contacts. Staff have to undergo a CRB (Criminal records bureau-police check) and POVA pre employment check. Once this has been obtained records of the outcome, date and disclosure number are recorded to show that the check has been performed, although the level of disclosure was not recorded. The manager gave assurances that this would be done. One member of staff had been working at the home for a considerable number of years. There was no evidence that a POVA check had been performed. The manager gave assurances that this would be done. These shortfalls are reflected in the recruitment section. People who use the service are supported in managing their individual bank accounts. Appropriate systems are in place where people have money stored at the home. Two signatures are obtained and record of receipts kept. All cash boxes checked had the correct balance present. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Chimes is kept clean and comfortably furnished and the residents live in a pleasant and homely environment. EVIDENCE: The Chimes is very conveniently situated being within walking distance of the town centre, bus and rail services. People living at The Chimes have a clean, comfortably furnished and attractively decorated home environment. All rooms are used at present for single occupancy and all have ensuite facilities. There is one larger room available for two people who may make a conscious choice to share a double room. There is only one communal bathroom but some of the people have ensuite shower facilities so this is adequate for the needs of the home. There is a bath hoist available for some people in the home. Staff are trained on an individual basis for the use of this equipment. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 21 There is a spacious and well-used lounge with TV and a large dining room where many other activities take place. The kitchen is not large but meets the needs of the people who use the service. There are ramps for those people that use wheelchairs, but access for these people is restricted to the first floor. The laundry facilities are on the first floor and not accessible to service users who use wheelchairs. Washing machines are domestic in style, which is appropriate to the needs of people who use the service. There is a basement that has recently been risk assessed and converted into a games room with pool table, darts board and table tennis table. All areas of the home appeared to a high standard. Many areas had been redecorated. Tables have been varnished, walls and some rooms re painted. Some carpets have been replaced and new bedding and curtains purchased for some people. Rooms in the home reflected the individual needs and preferences of people in the home. Some rooms were full of ornaments and personal belongings and others were plain and minimal. A maintenance man attends the home each week when the least amount of people are at the home in order to reduce disruption. Communication books ensure work needs are passed on promptly. The outside of the home has recently bee repainted and attractive plants were present in the back garden. Staff told us one of the people at the home likes gardening and had assisted with the borders and planting. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are cared for by a stable staff group who have had sufficient pre employment checks. EVIDENCE: People who use the service like the staff at the home who care for them. Surveys received from people who use the service showed us that people are happy living at the Chimes. Comments included ‘The staff are always lovely and kind’ and ‘I like all the staff’. Relatives were asked what the service does well. One comment read ‘Dealing with a range of clients and their diverse needs. Dealing with us!! and other relatives. Developing and maintaining a happy atmosphere’. There were appropriate displays of affection shown by people towards the manager and staff at the home. These were managed well and sensitively. The staff we spoke with said they were happy with the hours they worked each week and did not feel tired. Staff told us they had attended in house induction The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 23 and recent training sessions. Staff explained they have a training folder where certificates and training materials are stored. Two of the three staff files we looked at showed that staff had achieved NVQ (formal national qualification) 4 in care. Staff we spoke with said they had attended courses in epilepsy awareness, mental capacity act and medication. The manager showed evidence that staff had been booked on total communication training courses in November 2008. The manager explained that a new distance learning training programme is also being introduced. Staff explained that staffing levels are stable and agency staff are not used as sickness and holiday leave are covered by existing staff to keep continuity for the people who use the service. The manager performs appraisals and one-to-one supervision. Staff meetings are held and minutes were seen. Records showed that recruitment was good at the home. Staff are expected to fill in an application form and provide forms of identification for the CRB and POVA checks. Staff have to under go a CRB (Criminal records bureau-police check) and POVA pre employment check. Once this has been obtained records of the outcome, date and disclosure number are recorded to show that the check has been performed, although the level of disclosure was not recorded. The manager gave assurances that this would be done. One member of staff had been working at the home for a considerable number of years. There was no evidence that a POVA check had been performed. The manager gave assurances that this would be done. A health questionnaire is completed and two written references are obtained. A record of interview is recorded on the back of the application form. Staff told us that people who use the service are involved in the interview process. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. 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 home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42,43 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. EVIDENCE: The manager has a professional nursing qualification and is therefore fully qualified to manage a care service. She also has completed a National Vocational Qualification in Management at Level 4. Staff told us they were clear about what was expected of them and felt supported by the manager. The staff we spoke with said the manager was approachable and very supportive. The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 25 Staff said they felt able to share new ideas and felt that they are listened to. An example of this was given at the inspection. Staff explained that staff had suggested a way staff could be alerted to a particular problem at night. This was then implemented. The manager has introduced a new quality assurance system. Questionnaires were sent to people who use the service, their families and health care professionals. Evidence was seen to show that issues raised had been addressed such as décor in the home. Records are kept of staff training. These include mandatory training. The manager explained that some of this training is performed in house such as infection control. In addition to this the manager accesses control of infection training from NHS services such as essential steps. The manager also explained that some staff have attended the council safer food better business training, as well as the food safety training. Staff at the home do not use hoists and moving equipment as part of their daily work. Where a bath hoist is required 1:1 training and an assessment is performed for the one hoist and person who uses this equipment. Maintenance records were available for boilers, electric meters, fire detection systems, prevention of legionella and waste management. Contractors are used for the majority of these services. Commission for Social Care Inspection and Insurance certificates are displayed in the home. Insurance certificates were also present for the homes vehicle. The Chimes DS0000070223.V368733.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 Adults 18-65 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 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 x x 3 3 The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 27 no 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The Manager should update all copies of the Statement of Purpose and Service User Guide to reflect the change in details and contacts of the Commission for Social Care Inspection. The manager should keep a central register of complaints to capture trends in issues and show that the home manage complaints and see the process as a quality assurance process. The Manager should ensure evidence is kept of what level CRB is performed and show whether a POVA is included within that check. 2 YA22 3 YA34 The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 28 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 The Chimes DS0000070223.V368733.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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