Care Home: Chacombe Park Care Home

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What the care home does well Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Care plans are made personal to each individual and contain much detail about people`s preferences as well as their hopes and concerns for the future. Care plans seen state the long term objective for each specific area as well as details of how staff should care and support people to achieve that objective. The general manager and the clinical manager both identified areas where the home could improve further and their intentions to affect change. Throughout the inspection staff were observed treating people with respect, for example addressing them by their preferred name. The home offers a wide range of activities for people to participate in if they wish to. One person was overheard telling staff that his lunch was “first class”. The chef was seen going around the tables after lunch asking people if they were happy with their meal, he stated that this is something that is done after every main meal. The home is spacious with the décor and furnishings being to a very high standard. What has improved since the last inspection? This is the first time that the home has been inspected since it was registered by Barchester Healthcare Homes Ltd. What the care home could do better: Care plans seen were only signed by staff and not by the person themselves. On one person’s individual plan of care a note had been made to say that the person did not wish to be resuscitated. This had not been signed by the person and there was no detail to show how this had been ascertained. There were some instances where the medication administration record had not been signed. Window opening restrictors have been fitted to all of the windows in the home but these are not adequate to ensure people’s safety as they can easily overridden causing a potential risk of someone falling out of a first or second floor window.Chacombe Park Care HomeDS0000073026.V376338.R01.S.docVersion 5.2The recruitment of staff is generally well managed, however a reference for one person recently employed was a personal rather than a professional reference being from a friend and former colleague rather than an employer. Some people spoken to indicated that the home was short staffed at times. One person told us that the night staff change frequently and that they do not like to see a strange face at night. Other people said that on occasions they had to wait a while for their call bell to be answered. The home does not currently collect any formal feedback, such as satisfaction surveys, from people living at the home or from staff. Key inspection report CARE HOMES FOR OLDER PEOPLE Chacombe Park Care Home Banbury Road Chacombe Banbury Oxfordshire OX17 2JL Lead Inspector Catherine Perrins Key Unannounced Inspection 3rd July 2009 11:50 DS0000073026.V376338.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chacombe Park Care Home Address Banbury Road Chacombe Banbury Oxfordshire OX17 2JL 01295712001 01295712100 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) www.barchester.com Barchester Healthcare Homes Ltd Vacant. Care Home 77 Category(ies) of Old age, not falling within any other category registration, with number (77), Physical disability (77) of places Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical Disability - Code PD The maximum number of service users who can be accommodated is 77 2. Date of last inspection Brief Description of the Service: Chacombe Park is set within extensive grounds overlooking Cherwell Edge golf course, in the village of Chacombe close to the market town of Banbury. The nursing home consists of a large two storey extension to the former main residence, which is now converted into retirement apartments. The furnishing and décor of the home is to a high standard and accommodation is comfortable and spacious. The home has two restaurants and several communal lounge areas. Barchester Healthcare Homes Ltd became registered with the Care Quality Commission as the providers of care at Chacombe Park 07/01/2009. Prior to this it had operated as a nursing home under a different provider. The home has a general manager and a clinical manager. The Clinical manager is in the process of applying to become the registered manager for the home. Fees at the time of inspection ranged from £605 to £1390 per week. Chacombe Park Care Home DS0000073026.V376338.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 two star. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection which means that we focussed on the ‘key’ national standards. The key standards are those considered by the Commission to have the most impact on outcomes for people who live at the home. As part of the preparation for this inspection a period of two hours was spent reviewing the information that CQC has about this service. We looked at all the information that we have received, or asked for, since the home registered with the commission on 7th January 2009. This included: The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the home has managed any complaints. What the home has told us about things that have happened in the home, these are called ‘notifications’ and are a legal requirement. Relevant information from other organisations. The inspection visit lasted eleven and a half hours during the morning and afternoon of two weekdays. During the inspection four people were ‘case tracked’. This involves looking in detail at all aspects of their care and experiences at the home, including looking as their individual plans of care and other records, talking to them and talking to their care staff. A sample of staff files were also viewed as part of the inspection. The general manager and the clinical manager were present during the inspection. What the service does well: Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 6 Care plans are made personal to each individual and contain much detail about peoples preferences as well as their hopes and concerns for the future. Care plans seen state the long term objective for each specific area as well as details of how staff should care and support people to achieve that objective. The general manager and the clinical manager both identified areas where the home could improve further and their intentions to affect change. Throughout the inspection staff were observed treating people with respect, for example addressing them by their preferred name. The home offers a wide range of activities for people to participate in if they wish to. One person was overheard telling staff that his lunch was “first class”. The chef was seen going around the tables after lunch asking people if they were happy with their meal, he stated that this is something that is done after every main meal. The home is spacious with the décor and furnishings being to a very high standard. What has improved since the last inspection? What they could do better: Care plans seen were only signed by staff and not by the person themselves. On one person’s individual plan of care a note had been made to say that the person did not wish to be resuscitated. This had not been signed by the person and there was no detail to show how this had been ascertained. There were some instances where the medication administration record had not been signed. Window opening restrictors have been fitted to all of the windows in the home but these are not adequate to ensure people’s safety as they can easily overridden causing a potential risk of someone falling out of a first or second floor window. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 7 The recruitment of staff is generally well managed, however a reference for one person recently employed was a personal rather than a professional reference being from a friend and former colleague rather than an employer. Some people spoken to indicated that the home was short staffed at times. One person told us that the night staff change frequently and that they do not like to see a strange face at night. Other people said that on occasions they had to wait a while for their call bell to be answered. The home does not currently collect any formal feedback, such as satisfaction surveys, from people living at the home or from staff. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Chacombe Park Care Home DS0000073026.V376338.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 Chacombe Park Care Home DS0000073026.V376338.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given good information and their needs are fully assessed to ensure that the home is right for them. EVIDENCE: The home has a statement of purpose and service user guide which give people good information about the home and the services it offers. A copy of these are available in the reception area of the home as well as in each person’s bedroom. The general manager told us that the service user guide can be made available in large print if required. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 10 Records show that people’s needs are fully assessed before they move into the home to ensure that the home is able to meet their needs. Initial assessments seen covered areas such as communication; personal care; mobility; continence; moving and handling; tissue viability; nutrition; pain; sleep; sexuality and relationships; hopes and concerns for the future; social interests and spiritual and cultural needs and gave good information about the care and support that people require. People told us that they were able to visit the home before they moved in to help them decide if it is the right move for them. If they are not able to visit, their relatives or friends can do so on their behalf. One person told us that she had been able to choose which room she wanted before moving in. The home has six bedrooms for people having ‘intermediate’ care. Intermediate care gives people short term rehabilitation whist they prepare to return home. People receiving intermediate care at Chacombe Park have a file detailing their planned rehabilitation in their bedrooms. Chacombe Park Care Home DS0000073026.V376338.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their health and personal care needs met and their preferences respected. EVIDENCE: Each person who lives at the home has an individual plan of care. This contains their care plans and other information that staff need to care for people in the right way. Care plans had been developed from the initial assessments carried out before people moved into the home. They covered areas such as communication; personal care; mobility; continence; moving and handling; tissue viability; Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 12 nutrition; pain; sleep; sexuality and relationships; hopes and concerns for the future; social interests and spiritual and cultural needs. People also had care plans for short term issues that they may require care or support with, for example if they had a specific short term health problem. Care plans seen detailed the long term objective for each specific area as well as details of how staff should care and support people to achieve that objective. Care plans contained much detail about peoples preferences for example one person likes to go to bed after news, another does not like to be brought a drink first thing in the morning. There was evidence of people being helped to make choices such as what clothes they wanted to wear. Care plans also detailed how one person liked to chose her own make up and perfume. Records show that care plans are reviewed and update on a regular basis, at least monthly. Care plans seen were only signed by staff and not by the person themselves. On one person’s individual plan of care a note had been made to say that the person did not wish to be resuscitated. This had not been signed by the person and there was no detail to show how this had been ascertained. Records show that people had been assessed to find out if they are at risk of developing pressure sores. Where it was identified that there is a risk measures are put in place to reduce the risk, such as provision of specialist equipment and helping people to change position regularly. The home involves a specialist tissue viability nurse and detailed records ensure that people are getting the care and treatment that they require. Individual plans of care contain details of assessments for the risk of people falling. Records also show that people’s needs in relation to nutrition and hydration are assessed. The home employs an occupational therapist and records show that people also have access to other health care professionals such as general practitioners, physiotherapists and podiatrists. The administration of medication is generally well managed. There were some instances where the medication administration record had not been signed. The clinical manager was aware of these instances and had been able to ascertain that people had still received their medication as prescribed. The clinical manager explained that the nursing staff were all undergoing a competency assessment for administering medication. The clinical manager outlined a number of areas where she felt that the home had made good improvements over the last few months to improve care Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 13 practices, these included continence care, end of life care and medication administration. Throughout the inspection staff were observed treating people with respect for example addressing them by their preferred name. A member of the domestic staff explained that she always knocks on people’s bedroom doors and asks their permission before entering. Chacombe Park Care Home DS0000073026.V376338.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to a variety of activities and enjoy a good standard living. EVIDENCE: The home employs two activities coordinators. People’s individual plans of care contain some information about their interests and hobbies. One of the activity coordinators informed us that she was in the process of compiling life histories for each of the people at the home. This is important as it means that activities can be offered that reflect the interests of the individuals who live at the home. A ‘social and entertainment diary’ for the month is given to each person living at the home to ensure that they are aware of the activities on offer each day. Activities available include crosswords, quiz, flower club, book club, social Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 15 evening, knitting group, movement to music, short mat bowls, reminiscence, pub lunch, yoga, library, indoor horse racing, cookery group and skittles. On the first day of inspection a group of people were seen enjoying watching Wimbledon in one of the communal lounge areas. On the second day a group of people went out to Cotswolds Wildlife Park. The home has a minibus to make it easier for people to go out for the day. The activity coordinators keep a record of who attends the various activities so that they can make sure that they visit people who do not attend any activities and spend some time with them if the people wish to. People told us that communion was held in the home every Friday and every second Monday. Information from the local Parish Council is made available to people living in the home in the form of a newsletter. At 12:30 each day sherry is served in one of the communal areas and a small group of people were seen meeting to enjoy a sherry before lunch. One person, who is a model railway enthusiast, showed us the model railway he has designed and built with help from relatives and friends from the home. He has the use a large outbuilding, which is fully accessible for his wheelchair, to use for his railway and told us that he is able to go and spend time their regularly. Another person, who was not able to walk, told us that she would like to go out with staff in her wheelchair around the grounds of the home but that this had not happened. The home has two dining areas which are referred to as restaurants. The general manager explained that the home has purchased a ‘baine marie’ to transport the food from the kitchen and ensure that it is still hot when it is served. Lunch time was observed on the first day of inspection. One person was overheard telling staff that his lunch was “first class”. People are able to choose their meals the previous day. The chef explained that if people change their mind or if they do not want what is on the menu then alternatives are always available. For example one person did not like anything on the menu on the first day of inspection so the chef went to speak to her and, on her request, prepared her a salad for lunch. The chef explained that people can have either a cooked breakfast or cereal and toast in the morning; Lunch is a three course meal and is the main meal of the day. The main course is served with three vegetables and potatoes. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 16 High tea is served at 3pm and consists of homemade cakes and tea is usually soup or sandwiches. The chef was seen going around the tables after lunch asking people if they were happy with their meal, he stated that this is something that is done after every main meal. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is taking necessary measures to ensure that any issues that affect the health and well being of people are addressed. EVIDENCE: The home has a complaints procedure which outlines what people should do if they wish to raise a concern about the home and the response that they can expect. Records show that the home has received four complaints since Barchester became the registered provider in January 2009. Documentation seen showed that the management of the home responded promptly to concerns raised in line with the home’s complaints procedure. Records show that there have been two occasions where alleged staff conduct has resulted in referrals being been made to the Local Authority under the locally agreed safeguarding adults procedure. Documentation shows that Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 18 appropriate action has been taken by the home in these instances to ensure that the people involved either do not work at the home or receive further guidance and training to ensure that they care for people in the right way. There have been six instances since the new registration where people staying at the home have had their personal belongings stolen. The home is working with the police and the safeguarding adults team at the Local Authority to prevent this from continuing to happen. Lockable facilities are available for people in their bedrooms and the general manager explained that people have been made aware of the need for extra vigilance. People are able to lock their bedroom doors if they wish to. The general manager explained that where people have had items stolen the home has offered them compensation in the form of additional services as a good will gesture. The general manager stated that all staff had received some training on safeguarding adults but the some people were due for updates. Staff spoken to knew how to raise any concerns that they may have. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy a very high standard of accommodation. EVIDENCE: Chacombe Park is set within fifteen acres of gardens. The nursing home consists of a large two storey extension to the former main residence which is now converted into retirement apartments. Pleasant views of the grounds can be enjoyed from most of the windows. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 20 The home is spacious with the décor and furnishings being to a very high standard. There are two ‘restaurants’ on the ground floor where people are served meals. The tables in these rooms are dressed with table clothes, napkins and a small vase of flowers and arranged so that people can sit in small groups. There are several communal lounge areas all of which are made comfortable and homely with pictures, plants, books and magazines. Facilities for residents or visitors to make drinks are available in most of the lounge areas. The first and second floors can be accessed via a passenger lift as well as stairs. All of the bedrooms in the home are en suite, some having an en suite wet room whilst others have just a toilet and wash basin. Several bedrooms have patio doors leading to either the gardens or to a balcony. Bedrooms seen were spacious and had been made very personal by the people staying in them with pictures, photographs, ornaments and other personal effects. Communal bathrooms are available on each floor offering accessible bathing facilities. There is a large activity room where some of the home’s activities are held. All areas of the home seen were clean and well maintained. Window opening restrictors have been fitted to all of the windows in the home but these are not adequate to ensure people’s safety as they can easily overridden causing a potential risk of someone falling out of a first or second floor window. The general manager stated that he was aware of this issue and that it was being addressed as a priority. Within the grounds of the home there are a number of paths where people can enjoy walks, seated areas and an outdoor fitness area which is accessible to people who use wheelchairs. The home employs a maintenance team and a gardener to ensure that the property and grounds are maintained to a high standard. Chacombe Park Care Home DS0000073026.V376338.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a caring and respectful staff team and the recruitment of more nursing staff to fill current vacancies will ensure people’s needs can be fully met. EVIDENCE: The recruitment of staff is generally well managed, however a reference for one person recently employed was a personal rather than a professional reference being from a friend and former colleague rather than an employer. All other pre recruitment checks had been carried out to ensure that staff are suitable to work with older people. One person told us that the staff are “very good” saying she “have nothing to complain about.” Some people spoken to indicated that the home was short staffed at times. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 22 One person told us that “the night staff change frequently I do not like to see a strange face at night.” Other people said that on occasions they had to wait a while for their call bell to be answered. The general manager explained that the home have recently recruited a number of care staff to fill staff vacancies but that they still need to recruit nursing staff as at present they are relying on nurses from an agency to cover shortfalls in the rota. The clinical manager told us that the home use the same members of agency staff wherever possible to promote consistency for the people who live at the home. She explained that the agency that they use supply a high calibre of nursing staff, however there are some tasks that only the regular nursing staff can fulfil such as being someone’s ‘named nurse’ or updating care plans meaning a higher workload for the regular staff. Staff were observed caring for people in sensitive and respectful manner and their interactions with people showed that they had a good relationship with the people they were caring for. Staff explained that they attend training courses such as food hygiene, safeguarding of adults, dementia care, infection control, health and safety, fire safety and moving and handling. Chacombe Park Care Home DS0000073026.V376338.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed but further clarity in the roles of the managers would ensure that the managers were able to work together and ensure the best interests of the people living in the home are paramount. EVIDENCE: The home is managed by a general manager and a clinical manager. Although staff spoke favourably of the managers, some staff spoken to were unclear Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 24 about the remit of each manager. The clinical manager is in the process of applying to become the registered manager for the home. The home gives satisfaction surveys to people who leave the home after their stay, these generally showed a good level of satisfaction. The home does not currently use any surveys with existing people within the home or staff. The clinical manager conducts monthly audits on individual care plans to ensure that they contain all the information needed to care for people in the right way. Records show that the necessary safety checks such as fire checks, checks on the water system and portable appliance testing have all been carried out recently. Hoists and lifting equipment has been serviced as per manufacturer’s recommendations. The general manager and clinical manager outlined plans to develop and improve the service offered by the home. Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 25 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X X 3 X x 2 Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement Arrangements should also be made to ensure the accurate recording and safe storage and administration of all medication to ensure that people have their medication as prescribed. Appropriate numbers of suitably qualified, competent and experienced staff should be employed to ensure the health and welfare of the people living at the home. Where temporary staff are deployed this must not prevent people from receiving continuity of care as is reasonable to meet their needs. Two written professional references should be obtained prior to any staff member commencing employment within the home to ensure the suitability of staff to work with older people. Timescale for action 29/07/09 2 OP27 18 02/10/09 3 OP29 19 15/07/09 Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations Care plans and other documentation pertaining to people’s care should be signed by the person to show that they are in agreement with the way that their care is to be delivered. Individual plans of care should be reviewed to ensure that they comply with the Mental capacity Act 2005 and British Medical Association and Royal College of Nursing guidelines on ‘Decisions Relating to Cardiopulmonary Resuscitation’ Dated October 2007 Window locks which restrict the amount that windows will open should be fitted to the first and second floor windows to ensure the health and safety of people living in the home. Quality assurance measures should be put in place which seek the vies of the people living at the home, their relatives and representatives and staff to ensure that the service is responsive to the needs and aspirations of the people living in the home. 2 OP11 3 OP38 4 OP33 Chacombe Park Care Home DS0000073026.V376338.R01.S.doc Version 5.2 Page 28 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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