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Archived: Chiltern Court

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Inspection report

Date of Inspection: 20 December 2011
Date of Publication: 20 January 2012
Inspection Report published 20 January 2012 PDF | 74.71 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider and carried out a visit on 20/12/2011.

Our judgement

Systems were in place to assess quality of care to ensure it met people's support needs, although we noted some gaps in risk and review management practices relating to catering risk assessments and part of a sling hoist which had been left charging on the floor of the downstairs corridor. Overall, we found that Chiltern Court was meeting this essential standard but, to maintain this, we suggested that some improvements were made.

User experience

People using the service did not comment on this outcome.

Other evidence

We were told that Four Seasons would be replacing the existing quality manual in February / March 2012.

The registered manager said a new system of audit the ‘home audit process tool’ was being introduced into the homes by Four Seasons. We saw the new audit tool incorporated audit timelines, for example; a 60 bed home would receive non-compliance monitoring every six-weeks. The types of audits identified within this new tool related to care documentation, medicines, nutrition and safeguarding of vulnerable adults. As this was a new audit tool the registered manager said that her current audit programme included audits from the predecessor organisation. During the visit we saw that a number of audits had taken place at the home throughout 2010 – 2011. We saw a random selection of audits.

The home’s last environmental health audit took place in March 2010 resulting in a five star rating award.

Daily and weekly equipment cleaning rotas were in place. Random reviews of these documents showed that checks had taken place and the records had been dated and signed by the staff member who had completed the checks. We also saw completed fridge and freezer temperature records.

Monthly audits had taken place in relation to medication, catheters, care reviews, weight loss and pressure sore monitoring. We were told that any changes resulting from audit findings had been communicated to staff at either staff or registered nurse meetings.

We saw systems in place to manage risk. People’s care files showed that individual risks had been identified and appropriate actions identified. Associated monitoring and review dates against each risk were seen and had taken place. People’s dependency levels had also been identified and monitored monthly.

During our tour of the kitchen we noted that catering risk assessments relating to kitchen equipment had not been updated since February 2007. The risk assessment document confirmed that these risk assessments should be reviewed annually. The home did not identify that a plan had been put in place to review the catering risk assessments. A catering hazard analysis and critical control point checklist was displayed.

During the tour of the home we observed part of a sling hoist had been left charging on the corridor floor on the ground floor. This constituted a trip hazard. The registered manager said that it was not normal practise to charge a sling hoist on the floor and a risk assessment relating to charging sling hoists did not exist.

We tracked two incidents which confirmed that full investigations had taken place and actions identified. We saw that people’s care plans had been reviewed and updated following the incidents and explanations had been given to people’s relatives about the outcomes, the new care plans and / or actions.

Discussions with staff confirmed staff meetings took place and systems were in place to monitor individual performance, for example: yearly appraisal and supervision sessions with trained staff.