Care Home: Chestnut House

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What the care home does well Residents` independence continues to be well promoted within the home. They commented that they felt able to make their own choices and were involved in decisions about the running of the home. All spoke positively about their relationships with the staff team and felt that they could talk to staff if they had any problems and would be listened to. There are a range of recreational and vocational opportunities and links with the local community. Residents have opportunities to attend local college courses, leisure centres and employment opportunities for example if they wish. What has improved since the last inspection? Residents continue to have opportunities to promote their independence and to have support to work towards living independently, or to be as independent as possible within the service. Residents told us of their wishes for the future and how they are being supported to achieve them. The manager confirmed that changes have been made to ensure that staff always contact emergency services or seek medical advice in the event of an accident occurring and there is a better system in place to monitor staff that work individually with residents to ensure their welfare and safety. Residents have opportunities to join in with staff training if they wish. There has also been a general study done about the mealtime provisions of all Prime Life services, with the intention of sharing ideas and initiatives which may better meet the needs and preferences of people who use the service. Residents were complimentary about the meals provided. CARE HOME ADULTS 18-65 Chestnut House 62 High Street Marton Lincolnshire DN21 5AW Lead Inspector Sue Hayward Unannounced Inspection 5 March 2008 10:30 th Chestnut House DS0000061665.V358319.R02.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 Chestnut House DS0000061665.V358319.R02.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. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnut House Address 62 High Street Marton Lincolnshire DN21 5AW 01427 718272 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) Prime Life Ltd Mrs Margaret Turner Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Prime Life Care Limited owns Chestnut House. It is a detached adapted property set in an extensive plot of land, which is registered to provide care and accommodation for up to nineteen clients with mental health needs. The home is situated in the village of Marton, approximately five miles from Gainsborough town and ten miles north west of the city of Lincoln. The village has a pub and two Churches. Other facilities are available both in Gainsborough and Lincoln. There is a public bus service that stops on the main high street near to Chestnut House. The home also has the shared use of a minibus with another service operated by Prime Life in the area to take clients to day care services, trips or appointments. There is a charge for this service. Bedrooms are located on both floors. There is a lounge and a lounge/dining area on the ground floor and there is a courtyard to the rear of the property, which includes a conservatory and is the designated area for people who wish to smoke. The home does not have a lift. Access to the first floor is via stairs. It has a large car parking area to the side of the house and garden to the rear and side of the property. Information provided at the time of the site visit indicated that the current weekly fees are £361 - £550 per week. Chiropody and use of the services minibus is charged additionally to the fees. Chestnut House DS0000061665.V358319.R02.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 that people who use this service experience good quality outcomes. This was an unannounced visit and it formed part of a key inspection. It started at 10:30 and lasted 6 ½ hours. It took into account information we already hold on our files, which was used to plan the visit and produce this report. This included the previous inspection report and records of any incidents notified to us since the last inspection. We had asked for a selfassessment questionnaire to be completed prior to the visit. This gives an opportunity for the company and manager to tell us about their plans and how well they feel they are meeting standards. For example, what they do well, what they hope to improve and how they ensure residents’ (which is the collective term people who live in the home prefer to be referred as) are involved in decisions about how the service operates. It also includes some specific data, which enables us to send out surveys to people before we visit the service. This however, was not returned to us prior to the site visit. The site inspection focussed on key standards, which have the potential to affect the health, safety and welfare of people who use the service. The main method used for this was “case tracking” a sample of two people via their records and assessing their care. Three people were spoken to individually and four people were spoken to as a group. Four people were happy to show us their bedrooms. One person did not wish to speak with us. In addition we spoke to two staff members. The manager was present throughout and was given general feedback at the end of the visit. What the service does well: Residents’ independence continues to be well promoted within the home. They commented that they felt able to make their own choices and were involved in decisions about the running of the home. All spoke positively about their relationships with the staff team and felt that they could talk to staff if they had any problems and would be listened to. There are a range of recreational and vocational opportunities and links with the local community. Residents have opportunities to attend local college courses, leisure centres and employment opportunities for example if they wish. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 7 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 Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 8 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): Standards 1, 2 & 5 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good systems in place to introduce and assess people to ensure their care needs are identified and can be at the home met prior to admission. EVIDENCE: The service has information on display, which tells people about the service and what they can expect. This includes a document known as the statement of purpose. It was noted that this was last reviewed in January 2007. Discussion with the manager indicated that information about the service was not available in other forms such as audio or different languages on the premises but if needed this would be provided by the company. The manager also said that another way this information is provided is through discussion and reading documents to residents if they wish. A resident confirmed this saying staff would “read bits out to you if you want”. The manager also showed a photograph album that is being put together. This can be used to show prospective residents the sort of things they can participate in and the different aspects of life at Chestnut House. Records checked contained information, which showed that each resident had had an assessment completed by staff of the home and also based on Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 9 information from other relevant people such as social workers. From this care plans are developed and where necessary risk assessments documented. Assessments had included obtaining a range of information about people such as their preferred form of address, medical history and medication needs, brief life history and cultural and religious needs. Residents spoken to commented positively about the care and accommodation provided. Everyone spoken with was aware of the records held about him or her. Residents personal records checked showed that all had been given information about the terms and conditions of residency at the home. However, information about the terms and conditions does not include what timescale the “trial period” covers. Letters demonstrating that residents had had confirmation in writing of the outcome of their assessment were not seen on individual files checked. The manager said that this information is held at the company’s head office. There are satisfactory company policies and procedures about admission and discharge and residents have the opportunity to visit before making any decisions about whether the home is appropriate for them. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 10 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): Standards 6, 7 and 9. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from being involved in the planning and review of their care. Staff have a good knowledge of peoples needs and how to meet them, which contributes to ensuring peoples health and welfare. EVIDENCE: Comments from residents spoken to on the day confirmed that they felt their privacy and dignity was respected and their independence promoted. They said that they felt able to make their own choices and decisions about their lifestyles and confirmed that they are involved in the development of their care plans and reviews. Records kept showed when reviews had occurred. Discussion with staff indicated that they had a good knowledge of residents needs. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 11 Those care plans checked contained signatures of residents to denote their involvement and agreement with them or if unable to do so, signatures to denote the involvement of their relatives. From discussion with residents and checking a sample of care records information was in place to demonstrate that assessments are completed in relation to aspects of residents lives which have the potential to pose risks, such as smoking, scalding and personal hygiene. Staff clearly showed ways in which they respect residents’ privacy. For example the records of one resident was not made available, as the resident was not present at the time to give permission. It was said by the manager that the resident would want to be consulted about this. Whilst this is good practice and we would wish to respect residents wishes, there was nothing recorded on those care plans seen to indicate this policy had been discussed and agreed with residents. Residents need to be aware that there may be occasions (in order to ensure residents welfare and safety), when it is necessary to see records held about them. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 12 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): Standards 12, 13, 15, 16 and 17 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to pursue a range of activities and leisure interests both within the home and community, which are based on their individual needs and preferences. The meals provided are well balanced and cater for their individual preferences and specific dietary needs. EVIDENCE: Discussion with residents confirmed that they have opportunities to pursue recreational, educational and vocational interests if they choose. For example one resident confirmed she had been swimming on the day of the visit, another that they were able to go out shopping if they wished. The manager was in the process of arranging a social event with another Prime Life service on the day of the visit. Those records checked included a section for recording any specific needs of residents such as their spiritual or cultural needs. They Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 13 also contained information demonstrating activities they had participated in. One resident confirmed that they had recently participated in a health and hygiene course and was waiting to do a cookery course. Residents said they can use the organisations mini bus, which they have shared use of with another Prime Life service in the area, to get out and about or can use public transport if they wish. Discussion with service users also confirmed that they are able to keep in touch with families and friends and are able to have visitors when they wish. Records are kept of visitors and any contact with relatives, friends and other professionals. All residents made positive comments about the food provided and said there was a choice of meals. There is a kitchenette for residents to use where they are able to make their own drinks and meals using a hob, however there is not an oven. The manager confirmed that this was to be provided and will then increase opportunities available for people who use the service to develop their cookery skills and prepare them for living independently. Personal records contained information, which demonstrated whether residents had any specific dietary needs and these were known by staff. Menus showed that varied meals are provided. There was evidence seen which demonstrated that the service achieved a 4 star food hygiene rating from East Lindsey Environmental Health Services on 12th July 2007. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service receive the support and care they need to be as independent as possible and to promote their physical and emotional wellbeing. There are satisfactory systems in place for the storage and administration of medication in the home, which helps to keep people safe. EVIDENCE: Residents said that they are able to seek medical assistance when they wish and that appointments could take place in private or with a staff member present if they chose. Records checked contained information demonstrating that residents are able to visit or receive visits from a range of health professionals such as doctors, dentists, opticians and chiropodists. Information contained in records also gave details of any health care needs. For example a record had been made of a residents allergy to a specific medication. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 15 There are procedures in place, which inform staff of the actions to take to promote residents’ health and well being, such as a procedure to follow in the event of an accident occurring. Since the previous inspection report the organisation has received a complaint about the response taken following an accident, which occurred to a resident. This was discussed with the manager who agreed that the proper procedure was not fully followed on that occasion. She said action has since been taken to ensure that in the event of an accident occurring emergency services are contacted or advice is taken from a general practitioner in the first instance, and for staff to accompany as needed. Staff discussion confirmed they knew the accident procedure to follow and said they generally accompanied residents if they needed to go to hospital. Residents’ views confirmed that staff would contact a doctor or the emergency services and gave a recent example where this had happened. Both staff members asked confirmed they had had first aid training but training records made available did not demonstrate all care staff had had such training. (See comments and recommendations in relation to staffing standards). There are satisfactory policies and procedures in place to ensure the safe handling and administration of medicines. Staff spoken to and training records confirmed that only appropriately trained staff are responsible for administering medication. Residents said that they can take responsibility themselves for looking after their own medication providing there has been discussion and agreement with their doctor and they have been assessed as safe to do so. A resident who does this said she had been provided with a lockable facility to store her medication to ensure it is kept safe. The storage arrangements for medication administered by staff are satisfactory and the sample of records checked were well maintained and up to date. The manager said that she was trying to arrange a visit from a local pharmacist. It is noted that this comment was also made in the previous inspection report and has been raised in reports by the services own quality monitoring systems. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 16 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): Standards 22 and 23. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service feel able to raise concerns and complaints and are confident they will be dealt with. However the lack of up to date procedures may put residents at risk. EVIDENCE: One safeguarding adults issue has occurred since the previous inspection, which was referred appropriately and has been investigated. As a result of this the manager said she had taken action to improve the systems in place to monitor staff when working individually with residents, which now included ensuring detailed records are kept of what occurs during such times and checks by the manager through discussion with residents. The organisation has received a complaint relating to the service but the complaints record provided at the time of the visit did not include any details about it. The manager agreed in future to keep records of complaints received by the organisation relating to Chestnut House in the services complaints record, which would include details of investigations, actions undertaken to address them and the outcomes. Residents said that they felt safe in the home and would feel comfortable to speak to staff and the manager if they had a problem. They also said that “residents meetings” were held which gave them an opportunity to raise any Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 17 problems. Minutes are kept to demonstrate matters discussed at these meetings. There is a satisfactory complaints procedure in place and there is a book and comment cards available in the front entrance hall for anyone to make any comments or suggestions about the service. The Local Authority Safeguarding Adults procedure was on display in the office however it was noticed that this was dated February 2005 and it has been reviewed and updated since then. The manager who was not aware of this agreed to obtain a copy. Information was provided to demonstrate safeguarding adults is included as part of the induction training programme that staff follow. Staff’s perception of whether they had received formal training about this from the organisation was not as clear although those staff asked could give examples of the forms abuse can take and knew of their responsibility to report such matters. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 18 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): Standards 24 and 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and tidy and provides a comfortable and safe environment for clients to live in, which meets their needs and personal preferences. EVIDENCE: Four residents showed us their bedrooms. They said that they were able to arrange them as they wished and they also took on responsibility for cleaning them, supported by staff if needed. Residents’ independence is promoted through having lockable bedrooms and keys to their own rooms. Residents made comments indicating their satisfaction with the accommodation and have been able to arrange their rooms according to their own preferences and tastes. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 19 Communal areas such as the lounge and lounge/dining room were tidy and in a satisfactory state of decoration. Residents said that they were consulted about colour schemes and carpets. There is a separate laundry room and residents said that they are able to do their own laundry, again supported by staff if needed. There were some areas within the home (such as some bedrooms), which were showing signs of wear and tear to the décor. The manager said there is an ongoing decorative programme, to address this and that the painters and decorators were due in April. Records are kept to demonstrate any matters, which require maintenance and staff and residents confirmed that a maintenance person generally visits on a weekly basis so most issues are attended to promptly. The manager confirmed that if any maintenance matters arose which needed more urgent attention then contact would be made direct with contractors. There are satisfactory policies and procedures in place for staff to refer to ensure that good standards of hygiene and infection control are maintained. Equipment such as gloves are available for staff to use. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 20 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): Standards 32, 34 and 35 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff employed to meet the current needs of residents. There is a satisfactory recruitment process in operation, which helps to ensure residents are protected. EVIDENCE: Residents’ comments about their relationships with staff were positive. They said they got on well with them and felt comfortable to talk over any problems. They said, “Staff are always available if needed”. Staff were also of the opinion that staffing levels were sufficient to meet the needs of current residents. The sample of staff rotas checked demonstrated that a minimum of two care staff are always on duty during the day and at night there is a wakeful staff member and a member of staff who sleeps on the premises but is on-call. Some residents also have an allotted number of hours each week for staff to work with them on an individual basis. The manager confirmed that currently this amounts to thirty-four hours. In addition there is a housekeeper who works Mondays to Fridays and a cook. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 21 Staff have recently attended training about dealing with challenging behaviour. Basic food hygiene training has been arranged to take place on 14th March 2008. Training records provided at the time of the visit showed that all staff had had training to induct them into the work but they did not demonstrate that all staff had had First aid training and some staff had not had manual handling training updated since 2005. The organisation has a training coordinator and the manager said training could be arranged. Staff on the day confirmed their training had included matters such as fire safety training and first aid. Seven staff out of the 11 who are employed have achieved a nationally recognised vocational award in care at level 2 or above and two further staff are working towards achieving this. There have been few changes to the staff team in the past twelve months, which helps to ensure that people receive consistent care. Any staffing shortfalls are covered by existing staff working additional hours or by staff from other Prime Life services providing cover as needed. Residents’ comments indicated that they were made aware of any new employees but were not involved with the staff appointments. The manager said that no new staff had been employed in the past year so records of recruitment were checked of two of the most recent employees. These demonstrated that criminal records bureau and protection of vulnerable adults checks had been made as well as obtaining personal references to ensure their suitability to work in a care setting. However, in one instance the start date was recorded prior to the date that a criminals record bureau check had been obtained. This was discussed with the manager who confirmed that the person concerned had been employed in another prime life service. It is acknowledged that such checks would be transferable. The manager agreed to obtain documentary evidence from Prime Life’s human resources department of this and forward it to us by 31st March 2008. Staff said they felt supported and valued in their work. Staff meetings are held and records are kept to confirm this. Staff also confirmed that there is a staff appraisal and supervision system in place. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 22 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): Standards 37, 39, 41 and 42 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are satisfactory arrangements in place to obtain the views of residents in order to develop the service and satisfactory systems in place to promote health and safety. However, records did not always demonstrate ways the service was being monitored to ensure good quality standards. EVIDENCE: Since the last inspection visit the manager has successfully undergone the process to become registered to manage Chestnut House. She has a recognised management qualification and said she had now completed a national vocational award in care at level 4 although is awaiting confirmation of this achievement. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 23 Residents were aware of who was in charge and observation throughout the visit indicated that residents had a good relationship with her and were comfortable to approach her with any query, as was staff. There are systems in place to monitor the quality of the service. These include resident and staff meetings, visits by a company representative who completes a report and a formal quality audit system, which includes obtaining the views of residents, staff and other professionals about the standard of the service. Residents confirmed that occasionally they are given forms to complete about the quality of the service. As it is now a year since the last quality review it is recommended that another audit be undertaken. There was also discussion with the manager about the annual quality assurance assessment document, which had not been received prior to this visit although was first requested in August 2007. The manager said she had completed it and forwarded it to her managers for checking. The manager said she would contact the organisations head office to ensure it was sent to us and a subsequent telephone discussion with her on 27th March 2008 confirmed that the organisation had now returned it. The manager confirmed that a company representative visits the service on a monthly basis however the most recent record available to show when the last visit had taken place was dated 8th November 2007. There are a range of policies and procedures regarding health and safety available to guide and instruct staff. There is also a programme in place to service and maintain equipment in the home on a regular basis for example certificates were available to demonstrate the fire extinguishers were serviced in January 2008. A sample of records were seen which demonstrated that health and safety matters were being checked regularly, for example records showed that fire alarm tests are carried out weekly. Portable electrical appliances were last tested in January 2007. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 3 2 3 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 2 3 X Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA22 Regulation 17 (1) (b) Schedule 4 11 Requirement Timescale for action 30/04/08 2 YA41 26 (5)(b) There must be records kept of any complaints detailing the action taken to investigate them and any actions and outcomes as a result of them. This will ensure that residents are well protected. There must be up to date 30/04/08 records kept which demonstrate that a representative of the company has visited the home on a monthly basis detailing areas checked and people spoken with. This will ensure that the quality of the service is being well monitored. 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 It is recommended that information contained in the services statement of purpose be reviewed to ensure that it reflects changes to our policy on the frequency DS0000061665.V358319.R02.S.doc Version 5.2 Page 26 Chestnut House 2 YA5 3 4 YA10 YA23 inspections will be carried out. This will ensure that people who use the service have up to date and accurate information available to them. It is recommended, in order to ensure that people who use the service are clear about the terms and conditions of occupancy at the home that timescales for trial periods are specified in this information. It is recommended as good practice that records clearly show that there has been discussion and agreement with residents as to their wishes with regard to access. It is recommended that an up to date copy of the Local Authority safeguarding adults’ procedures is obtained and staff are updated about it through training or other means to ensure residents are well protected from any potential risks. Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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 Chestnut House DS0000061665.V358319.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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