Inspection Report
We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.
Chelfham House Residential Home
Chelfham House, Chelfham, Barnstaple, EX31 Tel: 01271850373 4RP
Date of Inspection: 14 May 2014 Date of Publication: June 2014
We inspected the following standards as part of a routine inspection. This is what we found:
Respecting and involving people who use Met this standard services
Care and welfare of people who use services Met this standard
Safety and suitability of premises Action needed
Staffing Action needed
Assessing and monitoring the quality of service Met this standard provision
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 1 Details about this location
Registered Provider Mr Mark and Mrs Karen Hammond
Registered Manager Mrs Wendy Plant
Overview of the Chelfham House is registered to provide care and support service for up to 41 people who have a dementia type illness. The home is situated in Chefham just outside Barnstaple in North Devon
Type of service Care home service without nursing
Regulated activity Accommodation for persons who require nursing or personal care
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 2 Contents
When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.
Page Summary of this inspection:
Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 What we have told the provider to do 6 More information about the provider 6
Our judgements for each standard inspected:
Respecting and involving people who use services 7 Care and welfare of people who use services 9 Safety and suitability of premises 11 Staffing 12 Assessing and monitoring the quality of service provision 14
Information primarily for the provider:
Action we have told the provider to take 15 About CQC Inspections 17 How we define our judgements 18 Glossary of terms we use in this report 20 Contact us 22
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 3 Summary of this inspection
Why we carried out this inspection
This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection.
How we carried out this inspection
We looked at the personal care or treatment records of people who use the service, carried out a visit on 14 May 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider. We reviewed information sent to us by other authorities.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.
What people told us and what we found
We considered our inspection findings to answer questions we always ask: Is the service safe? Is the service caring? Is the service effective? Is the service responsive? Is the service well led?
This is a summary of what we found.
On the day of our inspection there were 35 people living at Chelfham House. The summary is based on conversations with five people living at the service, three relatives, five staff and the registered manager. We looked at records of people's care and quality monitoring systems used with the home. We also spent time observing how care and support was being delivered to people. Following the inspection we spoke with the community nurse team who make regular visits to the home.
If you want to see the evidence supporting our summary please read the full report.
Is it safe?
We found the service was not always safe because there were not enough staff on at all times to meet the complex needs of people living at the service. We have made this judgement based on our observations of how people were supported during the inspection visit, looking at staff rotas and by talking to staff about people's needs. We found that on
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 4 the day of our inspection, some people did not get their medication until 11.30 am. We have been assured however that this was unusual.
We saw people had to wait for staff to assist them with eating their meal. We found staff were rushed and could not always provide quality time to people. The provider did not have a tool to assess the dependency needs of people therefore we were unclear about how they had decided on the levels of staffing.
We found some areas of the home posed a potential risk to people, which meant they could be unsafe. For example we saw not all windows had been restricted. Some vanity units were chipped and would not be able to be cleaned in a way which would ensure against infection control. We found wardrobes had not been secured to walls and could easily be pulled over and cause an injury to people. The registered manager said she would address the environmental issues as a matter of urgency.
Is the service caring?
We found people were being supported by a staff group who showed a great deal of caring. Our observations showed although staff were busy, they provided people's care in a respectful and dignified way. Relatives we spoke with were very complimentary, one said ''I am so grateful, this home is very, very good. I feel they have given me my mother back.'' They explained their relative had been very sick prior to coming to the home and over time has improved, put on weight and ''getting back to being more contented and settled.'' Another relative we spoke with said '' You could not wish for better care, the staff are all very caring, they work very hard and they always put on a lot of entertainment.''
Is the service responsive?
The service was responsive to people's needs and wishes. For example where people's needs had changed, care plan information had been updated and equipment had been considered. Where people had injured themselves following a fall, medications reviews had been considered and well as ensuring the environment was safe, free from clutter and pressure mats being used to alert staff if people got up unaided from their bed for example.
Is the service effective?
The service was effective because it was clear from the discussions we had with visiting relative and the community nurse team, that staff knew and understood people's needs. When needs had changed healthcare teams were consulted and the approach appeared proactive in seeking the least restrictive way of supporting people. The Deprivation of Liberty safeguards had been appropriately used to ensure people's rights were upheld, but that the service continued to meet people's needs.
Is the service well led?
The service was well led by a manager and team of staff who have continued to develop their knowledge and skills with ongoing training.
Systems were in place to ensure people's views were listened to and where possible relatives were included in the running of the service as there was an active relatives association, which met with the manager monthly.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 5 You can see our judgements on the front page of this report.
What we have told the provider to do
We have asked the provider to send us a report by 21 June 2014, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.
Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.
More information about the provider
Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 6
Our judgements for each standard inspected
Respecting and involving people who use services Met this standard
People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run
Our judgement
The provider was meeting this standard. People's privacy, dignity and independence were respected. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.
Reasons for our judgement
People who used the service understood the care and treatment choices available to them. Most people living at Chelfham House lacked the capacity to understand treatment choices, but we saw examples of where staff worked with people in a way to help them maintain autonomy and make choices about everyday aspects in their lives. For example, we saw people were offered a choice of drinks and snacks. We heard staff talking to people about where they wanted to spend their time and whether they wished to join in planned activities during the day. People were asked where they wanted to eat their lunchtime meal and were offered support in a kind and respectful manner.
People expressed their views and were involved in making decisions about their care and treatment. For example one person told us ''I didn't get up till just now, I like to get up late and it's okay.'' We heard from another person about how they preferred to spend most of their time in their room and staff respected this decision and brought them their meals and drinks. We heard how they ''enjoyed a chat with the girls'' but for the most part liked to be left alone. For people who lacked capacity to make their views known, we heard from several visiting relatives about how staff kept them informed of any decisions about care and treatment. One relative said ''They will always ring and let me know if my relative is unwell or had a bad night, I feel they keep me informed of everything.''
People were supported in promoting their independence. For example we saw people had mobility aids to help them move around the home independently. In bathrooms there were raised toilet seats and grab bars for people to be able to use the toilet safely and if possible independently. Staff we spoke with and our observations of how care was being provided led us to judge that staff understood the importance of promoting independence in activities of daily living.
People's diversity, values and human rights were respected. For example we saw in the monthly newsletter, people's past hobbies and interests had been highlighted and
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 7 promoted. One person for example, had been a keen gardener and some raised planters and plants had been purchased so they could be supported to continue with this passion. We saw one room was being used by a married couple and they had chosen to bring in their own double bed. The service had also given them a room next to their bedroom to use as their own lounge area. This showed the service had thought about people's diverse needs and acted upon them.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 8 Care and welfare of people who use services Met this standard
People should get safe and appropriate care that meets their needs and supports their rights
Our judgement
The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.
Reasons for our judgement
During this inspection we spoke with five people about their experiences of living at Chelfham House. We also spoke with three visiting relatives. People were very positive about the care and treatment they received. One person said ''We have good staff, everything is taken care of, no worries.'' Another person told us '' I like it here, no problems.'' One visiting relative discussed the concern and worry they had gone through in placing their relative in a care home, but said ''I am so grateful, this home is very, very good. I feel they have given me my mother back.'' They explained their relative had been very sick prior to coming to the home and over time has improved, put on weight and ''getting back to being more contented and settled.'' Another relative we spoke with said '' You could not wish for better care, the staff are all very caring, they work very hard and they always put on a lot of entertainment.'' We saw there was regular paid entertainment a few times per week. On the day we inspected for example, there was a singer who spent time in the upstairs lounge singing with people for an hour.
People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We looked at four care plans and daily records in detail. We saw care plans had been developed from a pre- admission assessment of people's needs. The plans were developed over time, once staff got to know people, their likes and dislikes and preferred routines. We saw each plan had been reviewed at least monthly and where changes in need had been identified, care plans reflected these changes and told staff how to deliver care and support. Care plans included all aspects of personal care, healthcare and emotional well-being. Where people had dementia and complex needs, any triggers for behaviour which may challenge had been clearly identified with instructions for staff about how to divert or diffuse a situation. For example it was noted that one person would present with anxiety if they thought they hadn't been visited by their relative. Staff were reminded to reassure the person their relative had or would be visiting and to distract their attention by asking them if they wanted a drink usually a cup of tea. This meant staff had clear guidance about how to work consistently with people to ensure their needs were met in line with their care plan.
Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. For example, we saw each care file contained a number of
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 9 risk assessments which were kept under regular review. These included risks of poor nutrition or hydration. Where such a risk had been identified, food and fluid charts were kept and people's weight was closely monitored. We saw where there had been a significant drop in weight the person's GP had been contacted for advice and support. Some people had been prescribed supplementary drinks to boost their calorie intake.
We saw each person had a falls risk assessment in place as well as a moving and handling plan, which gave staff clear instructions about how to assist people move safely. Where people had a history of falls, measures had been put in place to reduce these risks, such as walking aids, pressure mats in bedroom areas to alert staff to the fact they were getting up and ensuring people had footwear which supported them to move safely. Where people had a number of falls, this was reviewed to see if further preventative measures could be put in place. The manager told us, often they asked the GP to review people's medications to check the combinations of medicines were not causing them to feel dizzy or be more prone to be unsteady on their feet. This showed the service were proactive in assessing and preventing risks where possible.
We saw people had been assessed for risk of pressure damage. Where a risk had been identified, equipment had been put in place to prevent or reduce the risk of pressure damage occurring.
People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards (DoLS). We saw there were three people who were currently subject to DoLS and these were being kept under review. There was evidence in other care files where people's rights had been considered and discussions had been held with the Mental Capacity assessor team within the local authority. This showed staff understood how to protect people's right using the right law and legislation.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 10 Safety and suitability of premises Action needed
People should be cared for in safe and accessible surroundings that support their health and welfare
Our judgement
The provider was not meeting this standard. People who use the service, staff and visitors were not always protected against the risks of unsafe or unsuitable premises. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
We looked at this outcome as we had received two safeguarding alerts in recent months and both had mentioned people had said rooms were either unclean or not in a good state of repair. During this inspection we looked at all bedrooms and communal areas. We found rooms were clean and most were in a good state of repair. We found two rooms where the vanity units were in need of being replaced as it would have been difficult to ensure infection control standards due to chipped units. We also found most of the wardrobes were not secured to the walls, which meant they could be easily pulled down by someone causing injury. We spoke to the manager about this who said they would address this as a matter of urgency. We also found one window was cracked in one of the bedrooms, which needed to be replaced and not all windows had restrictors fitted. This meant people may be able to leave the building without staff being aware, or could be at risk of falling out of windows in rooms not on the ground floor. The manager said they would also address this as a matter of urgency.
We saw the use of good signage in large black print with yellow background. This helped to orientate people around the home. Name plates had been used for people's bedroom doors. We saw people had been able to personalise their own bedrooms.
We saw the communal bathrooms were kept clean but were drab and in need of refurbishment. One had a floor which had been patched up and this needed to be replaced. The bathrooms were not conducive to having a relaxing bath or shower. We concluded the provider had not taken steps to provide care in an environment that was always suitably designed and adequately maintained.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 11 Staffing Action needed
There should be enough members of staff to keep people safe and meet their health and welfare needs
Our judgement
The provider was not meeting this standard. There were not always enough qualified, skilled and experienced staff to meet people's needs. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report.
Reasons for our judgement
There were not always enough qualified, skilled and experienced staff to meet people's needs. On the day we inspected we were told there were 35 people living at the home. Nine people required two care staff to safely move them. At least 13 people required a care staff member to support them with their meals due to their dementia and or choking/frailty. We also heard there were six people being cared for in their own rooms with four of these being cared for in the bed so required regular checks and turning to prevent pressure sores developing. On the day we inspected there were five care staff plus the manager supporting people with their daily needs. We spent time observing how staff supported people.
We found the morning medication round was not completed until after 11.30 am. We asked if this was usual and heard that it not. The senior care staff member completing the medication round had been called upon to assist with safely moving people and to supervise people once they had been brought down to the main lounge following breakfast. This meant people may not be receiving their medications at the right prescribed time on the day of the inspection.
We observed people in the lounge downstairs calling out and not being meaningfully engaged with any staff for up to 20 minutes. When staff were available, in between getting people up, we saw positive interactions. Staff spoke with people to reassure them and to ask if they needed anything, but they were clearly busy getting other people up and could not spend long talking to people.
We observed lunch time period in the upstairs dining room/lounge. Three staff were available for this area and we saw they were attempting to assist five people who needed full support and supervision to eat their meal. One staff member was serving up the meals and the other two were assisting people. A fourth staff member was seen to be assisting people in their rooms. The lunchtime took over an hour for everyone to be assisted. We asked staff if this was the usual pattern for lunchtime period and heard that it was. We saw some people needed some supervision during this period, but staff were busy giving one
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 12 to one time to support people in eating their food. We observed one person take another person's pudding. Staff did intervene, but only after the person had started to eat the food. We saw another person become agitated with one of the other people living in the home. One of the staff had to stop assisting someone with their meal and intervene. It meant the person had several interruptions when being assisted and did not in fact eat much of their meal as a result.
We asked to see a sample of rotas for care staff covering shifts across the day and evenings. We saw there were usually five care staff per morning and evening shift and three care staff per waking night shift. We did however see on two weeks, the night shift was down to two care staff. With the number of people requiring two care staff to safely move and the number of people to turn and reposition to prevent pressure sores, two staff would not be sufficient to meet everyone's needs in a timely way. We asked if call bells were monitored to check if they were answered within an agreed timeframe and heard the service had not done this. We asked what dependency tool had been used to determine staffing levels based on the number and needs of people. We heard that the provider made the decision about numbers of staff based on the occupancy rate of the home. This did not take into account the complex and changing needs of people being cared for and this placed people at potential risk. The provider had failed to demonstrate they had carried out a needs analysis and risk assessment as the basis for deciding sufficient staffing levels.
We saw the ancillary staff who supported the service included three cooks and kitchen assistant and two cleaners. We heard how cleaning staff hours were being reviewed at based on lower occupancy levels. Given the size and layout of the building, it would be difficult to see how one cleaner could manage to keep the home clean to an acceptable standard. We have been notified of a sickness outbreak and a possible scabies outbreak, which meant the service needed to be extra vigilant with cleaning and ensuring deep cleaning took place.
When we spoke with staff, they said they were well trained and well supported to do their job. We heard about additional courses they have been asked to complete. We were told staff felt they were very busy and did not always have the time to spend talking to people as they had so many care tasks to attend to. Our observations concurred with this. Staff interacted with people in a kind and respectful way, but they were busy and did not have the time to spend chatting to people.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 13 Assessing and monitoring the quality of service Met this standard provision
The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care
Our judgement
The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive.
Reasons for our judgement
People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. Three relatives we spoke with during this inspection highlighted the fact they were regularly asked for their views both about their individual relative and the general running of the home. One relative said they had enjoyed being part of the relatives association which met once a month with the manager to talk about how the home was being run, activities and getting people out and about on trips. One relative said ''They are so good at involving us. I have helped to take people out to the local garden centre and they are always inviting relatives to get involved. It's a very inclusive place.''
Decisions about care and treatment were made by the appropriate staff at the appropriate level. We saw care files and care plans were regularly reviewed by the manager or deputy and where needs had changed, other healthcare professionals were consulted, such as community nurse, community psychiatric nurse (CPN) and GP.
There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. We saw for example falls were reviewed for any trends and measures were put in place to reduce the risk of falls. Where someone had behaviour which could challenge incident forms were kept and reviewed with the CPN to see if there was a pattern or trigger they could identify to anticipate and reduce the anxiety or challenge.
The provider took account of complaints and comments to improve the service. We saw complaints had been documented and fully investigated. Where people had made their concerns known to the local authority the manager had worked with them to gather information to ensure all complaints were fully investigated.
Systems were in place to review and monitor the service, records and environment, however the provider may wish to note, these did not pick up issues within the environment where people may be at risk. This has been detailed within outcome 10, but checks on the environment need to be through to include all risks.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 14 This section is primarily information for the provider
Action we have told the provider to take
Compliance actions
The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.
Regulated activity Regulation
Accommodation for Regulation 15 HSCA 2008 (Regulated Activities) Regulations persons who require 2010 nursing or personal care Safety and suitability of premises How the regulation was not being met: People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. This is in breach of regulation 15 (1) (b)
Regulated activity Regulation
Accommodation for Regulation 22 HSCA 2008 (Regulated Activities) Regulations persons who require 2010 nursing or personal care Staffing How the regulation was not being met: There were not always enough qualified, skilled and experienced staff to meet people's needs. This was because the provider had failed to demonstrate they had carried out a needs analysis and risk assessment as the basis for deciding sufficient staffing levels.
This is in breach of regulation 12
This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider's report should be sent to us by 21 June 2014.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 15 This section is primarily information for the provider
CQC should be informed when compliance actions are complete. We will check to make sure that action has been taken to meet the standards and will report on our judgements.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 16 About CQC inspections
We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re- inspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 17 How we define our judgements
The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected.
Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.
Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.
Enforcement If the breach of the regulation was more serious, or there action taken have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 18 How we define our judgements (continued)
Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.
Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.
Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.
Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly
We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 19 Glossary of terms we use in this report
Essential standard
The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:
Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20)
Regulated activity
These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 20 Glossary of terms we use in this report (continued)
(Registered) Provider
There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.
Regulations
We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.
Responsive inspection
This is carried out at any time in relation to identified concerns.
Routine inspection
This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.
Themed inspection
This is targeted to look at specific standards, sectors or types of care.
| Inspection Report | Chelfham House Residential Home | June 2014 www.cqc.org.uk 21 Contact us
Phone: 03000 616161
Email: [email protected]
Write to us Care Quality Commission at: Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Website: www.cqc.org.uk
Copyright Copyright © (2011) 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.
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