Inspection on 30/07/07 for The Chimes

This inspection was carried out on 30th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Chimes 30/07/08

The Chimes 21/06/06

The Chimes 08/11/05

The Chimes 02/12/04

The Chimes 24/06/04

The Chimes 18/04/04

The Chimes 26/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Chimes 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA Lead Inspector Pam Grace Unannounced Inspection 30th July 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 Chimes DS0000008211.V339893.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 Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chimes Address 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA 01782 744944 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr William Molton Mrs Marilyn Molton Mr William Molton Care Home 28 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (3) The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Chimes is a large, extended detached property located in a residential area in Penkhull. The home provides care for a maximum of 28 service users; their needs may range from old age to dementia and/or physical disabilities. The home can accommodate 2 people with dementia and 3 with a physical disability, the staff are trained in this area, and the inspection process confirmed the home is able to meet individual needs. The exterior and interior of the property are adequately maintained and redecoration is ongoing. The service users are offered easy access throughout the home by the use of stairs or a lift. Communal areas are spacious and comfortable; there are two lounges, which can be opened into one if required. The dining room is well maintained, sizeable and sited next to the kitchen. Small, quiet sitting areas are available on all floors. There are 26 single rooms, 12 with en-suite facilities and one double room with an en-suite. Bathrooms and toilets are appropriately situated. There is a garden area for service users and their visitors to use with appropriate seating facilities; adequate parking is available to the rear of the property. Local amenities are within a short walking distance. Local towns are accessible by car or public transport. Current fees range from £369.00 weekly, these are subject to annual review. Additional charges apply for personal toiletries, however there is no additional charge for hairdressing services. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken by one inspector, over two visits, and a period of approximately - 10 hours. The Registered Care Manager - Mr William Molton assisted the inspector throughout the inspection. The inspection had been planned with information gathered from the CSCI database, and the Annual Quality Assurance Assessment document (AQAA), which had been completed by the care manager. The key National Minimum Standards for Older Persons were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff and residents. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and the requirements and recommendations made. Residents spoken with were very positive about the care they were receiving. The inspector noted that residents appeared well cared for, and were happy in their surroundings. The Commission for Social Care Inspection (CSCI) received 9 “Have Your Say” documents from residents and relatives at the home. Feedback received was generally very positive, and included comments such as “I feel content and happy at the home”, “all the care I need is always met”. “There is a good choice of food to choose from”, ”my family visit me regularly, and we speak on the telephone each day”. “ If I want anything I can always ask the staff”. Enquiries had been made in relation to two anonymous concerns received by CSCI, both of which were not upheld. One complaint received by the home had been partially upheld and amicably resolved, since the previous inspection. Comments made by residents and staff during the inspection, were generally very positive. General observations were undertaken during the course of the inspection in relation to staff conduct and interaction with service users. There was a shortfall in the general standard of domestic cleaning at the home, particularly in communal areas, and a domestic staff member was in the process of being recruited at the time of this report. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 6 There were 4 requirements, and 7 recommendations made as a result of this unannounced inspection. What the service does well: What has improved since the last inspection? What they could do better: The maintenance of the home was satisfactory, however, some furnishings were in need of replacement, and the general standard of cleaning in some areas was quite poor. This included the garden area, the communal lounges, the kitchen floor, and the laundry floor. The Hobbies room needs total redecoration and refurbishment. This is a room which is used for smoking, and for hairdressing. Plasterwork to the wall in the middle floor toilet needs repair. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 7 Downstairs carpets require deep cleaning or replacement, particularly the lounge and dining room areas. The ranges of activities provided within the home need further development, and would benefit from ‘specialist activities’ for those service users with dementia and or sensory impairments. The home’s Service User Guide is about to be reviewed, this should be in an easy to read format. 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 DS0000008211.V339893.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 Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use this service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. The Chimes does not provide intermediate care. EVIDENCE: The Chimes had written information about the care home and the services provided. The home’s Statement of Purpose and Service User Guide was available and is currently under review. It was the home’s policy that prospective residents were subject to a pre-admission assessment to establish whether their needs could be met. Short stay admissions/trial visits were The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 10 available for residents before making a decision regarding admission to the home. Some information available on the home’s notice board was out of date. This was discussed with the care manager at the time, and suggestions made. Residents spoken with and feedback received by CSCI confirmed that prospective residents had visited the home with their family prior to making a decision and moving in. Residents spoken with said that the home was very comfortable and homely, and that all the staff including Mr Molton (Bill) had been very helpful. Contracts were not inspected on this occasion, however, all residents spoken with said that they had received a contract. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The inspector examined a sample of resident’s care plans, and spoke with residents. These evidenced that health and social care needs are being met, however care plans had not been reviewed since May. It is a requirement of this report that care plans are regularly reviewed. Visits by health professionals were appropriately documented and recorded, however, one assessment of need for a newly admitted resident was not completed, and although the resident had a poor appetite there was no inclusion of a weight chart with the paperwork. This was discussed with the care manager at the time and will be rectified. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 12 Residents who self medicate had risk assessments present in their individual care plans – however this practice is not consistently undertaken. One resident who was self-medicating, did not have a risk assessment in place. This was discussed with the care manager at the time. It is a requirement of this report that residents who self medicate must have an appropriate risk assessment. Staff were observed interacting with residents during the visit, they were courteous, respectful and polite, they knocked on doors before entering. Residents spoken with praised staff in regard to their politeness, and their caring manner. There was appropriate and timely referral for medical intervention. Routine medical procedures such as chiropody, dental, and hearing tests were accessed. The inspector examined the medication trolley, and checked medication administration records. These were found to be satisfactory. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use these services are able to make choices about their life style. However, they would benefit from specialist activities, i.e. for residents with dementia and or sensory impairments. Families and visitors to the home are welcome. Dietary needs of residents are well catered for. EVIDENCE: Residents spoken with confirmed that there is a mobile library service, that they watch television, and that there are some occasional music activities on offer at the home. Residents were also very complimentary about the food and meals provided at the home. Menus seen evidenced that residents do have a choice of meals. There was little evidence of equipment for activities in the home, or that activities are undertaken. For example games, puzzles and art equipment etc… This was discussed with the care manager at the time, and suggestions were made. Some residents would benefit from ‘specialist activities’, especially for those residents who have dementia and/or sensory impairments. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 14 Family and friends were welcomed and encouraged to maintain contact with residents in the home. The Commission for Social Care Inspection (CSCI) received 9 “Have Your Say” documents from residents and relatives at the home. Feedback received was generally very positive, and included comments such as “I feel content and happy at the home”, “all the care I need is always met”. “There is a good choice of food to choose from”, ”my family visit me regularly, and we speak on the telephone each day”. “ If I want anything I can always ask the staff”. One of the responses received by a resident, was that residents don’t want to go outside, as they fear a draught from the cold. The home has a small garden area and the garden was well maintained. However, the path around the garden was littered with cigarette butts and the area was generally dirty and uncared for. COSHH items were stood against the wall, and posed a hazard to residents. These were removed immediately and appropriately stored. The inspector noted during the inspection that the garden path was cleaned and tidied. Staff spoken with understood the needs of the residents very well. Residents confirmed that they could choose what they wanted to eat – and that they always had a choice of food on offer. The Chimes provides residents with a quarterly newsletter, this is sited on the notice board for visitors to peruse. Information within the newsletter included; planned events, birthdays, obituaries, poems, a staff fact file, a quiz and staff training qualifications. Residents spoken with confirmed to the inspector that they were able to see their friends and relatives any time they wished. There was evidence to confirm that people’s spiritual and religious needs were met. The home has a mini-bus which is used for trips out and transporting residents when required. Kitchen records in relation to hot and cold food temperatures were up to date. However, there was no cleaning schedule. This was discussed with the care manager at the time. Two freezers need replacing due to faulty and perished seals. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 15 and 18 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: There had been one complaint received by the home, and two anonymous concerns received by CSCI since the previous inspection. The complaint, which was partially upheld, had been dealt with by the care manager, and amicably resolved under the home’s own policy and procedures. Enquiries were made by CSCI at the time, in relation to two anonymous concerns. These were not upheld. However, the home’s system of recording complaints was not adequate for the task. This was discussed in detail with the care manager at the time, and suggestions for improvement were made. It is a recommendation of this report that a more robust system of recording complaints is implemented. Residents spoken with were very aware that they or their relatives could make a complaint if they wished to, and to whom they should speak to about a complaint. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 16 Staff spoken with confirmed their awareness of the need to protect vulnerable adults from abuse. However, this was not on their training agenda. This was discussed with the care manager in relation to the need to update all staff. It is a recommendation of this report that all staff should receive appropriate and updated training in relation to abuse, and the Protection of Vulnerable Adults (POVA). The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25 and 26 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home should enable people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The general standard of cleaning at the home was poor. EVIDENCE: The inspector undertook a tour of the building. The general standard of cleaning at the home was poor. Communal areas i.e. the downstairs small lounge floor, the kitchen and laundry floors, and the middle floor lounge floors were not clean, and some furnishings cluttered the upstairs lounge to the extent that residents or their visitors could not view the television in that area. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 18 The Hobbies room which is the designated smoking room for residents, is of a very poor standard, having been the home’s smoking room, it smelled strongly of cigarette smoke, the carpet was stuck to the floor and badly stained, and the room generally needs refurbishment and redecorating, this was discussed with the care manager, in the light of the fact that residents use this room for hairdressing. The area around the back of the home was full of cigarette butts, and did not encourage residents to use the garden. This was discussed in detail with the care manager at the time, and rectified during the inspection visit. The care manager confirmed that the kitchen floor is about to be replaced with appropriate non-slip flooring, and that the home is in the process of recruiting another domestic staff member, this will then mean that there will be two parttime domestic cleaning staff at the home. Kitchen records in relation to food temperatures both hot and cold, were up to date and in place. The home utilises the “Safer Food, Better Business” procedures which is recommended by the Food Services Agency. However, there was no robust cleaning schedule in place for the kitchen, this was discussed with the care manager at the time, and a schedule will be implemented. It is also a recommendation of this report that the two freezers identified, need replacing due to faulty and perished seals. The Annual Quality Assurance Assessment (AQAA) document that the care manager completed and forwarded to CSCI, confirmed that all safety checks on appliances, hoists, fire equipment etc.. had been undertaken. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home should be trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of service. EVIDENCE: 4 staff were spoken with, and staff recruitment records were sampled. Staff spoken with and records seen evidenced the need for staff to receive training in abuse and the Protection of Vulnerable Adults (POVA), and updates in Food Hygiene. Staff recruitment files seen confirmed that a robust procedure is in place. One CRB/Police check was later confirmed with the inspector. This had been mislaid at the time of the inspection visit. The Commission for Social Care Inspection is satisfied that all staff have received the necessary checks undertaken to ensure that they are suitable to work with vulnerable people. A training matrix was provided to the inspector, prior to the inspection. This did not contain up to date information in relation to all staff training undertaken or planned for. It is a recommendation of this report that an up to date training matrix is compiled and implemented. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 20 One staff member is a trainer for moving and handling. It is anticipated that that member of staff will be responsible for moving and handling training for all staff at the home. The care manager confirmed in the AQAA document that 4 staff members had enrolled for NVQ level 2 and or Level 3 training, and that 44 of staff at the home have achieved their NVQ Level 2 training, or above. The deputy care manager is currently undertaking her NVQ level 4 and Registered Manager’s Award. These will be completed within the next few months. The inspector confirmed with the care manager that some staff spoken with had said that they need their Food Hygiene certificates updating. The home’s new induction process was not inspected on this occasion. This will be monitored at the next inspection. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,35 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based upon openness and respect. EVIDENCE: There were many positive comments from residents in relation to the care and support that residents receive from Bill and the staff team. The Commission for Social Care Inspection (CSCI) received 9 “Have Your Say” documents from residents and relatives at the home. Feedback received was generally very positive, and included comments such as “I feel content and happy at the home”, “all the care I need is always met”. “There is a good The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 22 choice of food to choose from”, ”my family visit me regularly, and we speak on the telephone each day”. “ If I want anything I can always ask the staff”. However, there have been staff recruitment problems, and the general standard of cleanliness at the home had slipped. The care manager is fully aware of the shortfalls of the home, and is in agreement with the inspector in relation to the requirements and recommendations made as a result of this inspection. The AQAA document, which was completed by the care manager and sent to CSCI, and the outcome of this inspection visit, highlighted the areas that the home needs to improve on. Those areas include, staff supervision – which needs to be reinstated, Quality Assurance – which needs to be further developed, staff stability and staff training opportunities need improving, and the standards of cleaning must be improved both inside and outside the home. Quality Assurance and Staff Supervision will be monitored at the next inspection. A review of the Service User Guide – should include an easy read format, the home also needs to offer a wider range of activities to residents, with more local and community contacts. Activities should include residents who have mental health and sensory needs. Complaints are listened to and dealt with by the care manager in a timely and sensitive way. However, a more robust system of recording is needed. Enquiries made in relation to the two anonymous concerns that were received by CSCI, evidenced that these were not upheld. The care manager confirmed in the AQAA document that 4 staff members had enrolled for NVQ level 2 and or Level 3 training, and that 44 of staff at the home have achieved their NVQ Level 2 training, or above. The deputy care manager is currently undertaking her NVQ level 4 and Registered Manager’s Award. These will be completed within the next few months. Accidents and incidents are appropriately recorded. The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X 3 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X X 2 The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP9 Regulation 15(2)(b) 13(4)(b) Requirement The registered person shall keep the service user’s plan under review. A risk assessment and agreement referring to selfmedication must be in place, in all instances, in this case inhalers. Part Met. (previous timescale of 01/11/06 not met) COSHH items must be stored appropriately, for the safety of residents. The registered person must ensure that all parts of the home to which service users have access are as far as reasonably practicable free from hazards to their safety. Timescale for action 30/09/07 30/09/07 3. 4. OP38 OP38 13(4) 13(4) 30/07/07 30/07/07 The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 25 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. 6. 7. Refer to Standard OP16 OP26 Good Practice Recommendations There should be a robust system of recording in relation to complaints made about the service. All areas of the home should be kept clean, including kitchen, laundry, communal areas, and the external pathways of the building. The Hobbies room should be redecorated and refurbished. Staff should receive updates in Food Hygiene training. An up to date staff training matrix should be compiled and implemented. Staff should be updated in relation to abuse and the Protection of Vulnerable Adults training. The two freezers identified need replacement. OP26 OP30 OP30 OP30 OP38 The Chimes DS0000008211.V339893.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000008211.V339893.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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