Inspection on 22/02/08 for Charlton House

This is the latest available inspection report for this service, carried out on 22nd February 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Charlton House 31/08/05

Charlton House 29/03/05

Charlton House 03/09/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Charlton House 85 High Street Wickwar South Glos GL12 8NP Lead Inspector Grace Agu Key Unannounced Inspection 22nd February 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlton House 85 High Street Address Wickwar South Glos GL12 8NP 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) 01454 294167 Mr John Anthony Addle Mrs Teresa Addle Mrs Teresa Addle Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 4 persons aged 65 years and over requiring personal care only 22nd September 2006 Date of last inspection Brief Description of the Service: Charlton House is a small privately owned residential care home situated on the High Street in the village of Wickwar. It can cater for up to five elderly residents. The house was built in 1821 and has been refurbished to a high standard. There are three single rooms and one double, a well-furnished lounge and dining room, and a large kitchen. There is a large and attractive rear garden with lawns, flowerbeds and a fishpond. The owners live on the third floor of the house, which is situated close to several small shops in the village. Large shopping areas are available several miles away in Chipping Sodbury or Yate. The Home is close to the bus route for Chipping Sodbury, Yate, Bristol and Wotton-under-Edge. Charlton House 85 High Street DS0000003317.V359994.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 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced inspection site visit which was undertaken over eight hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at he home. We met with Mrs Teresa Addle the home manager and whilst touring the building, we spoke with four service users, one staff member, and a number of records were viewed. What the service does well: Evidence from records and speaking to the service users indicate that the home creates a safe, friendly and caring environment in which residents feel content and their needs fulfilled. Generally the home was found clean and warm and service users were found relaxed and some service users were seen accessing the communal area without restriction. Staff were noted interacting with individuals living in the home in an informal and sensitive manner A guide is given to prospective service users to enable them to make an informed choice about living at Charlton House and they are informed on admission of a one-month trial to enable them to make an informed decision whether to stay. The home has a good care planning system, which is holistic, and this specifies how identified needs are to be met. Care plans are regularly reviewed. Good meals are provided for the service users and staff ensure that meals are not hurried and those who have difficulties are assisted in a respectful, sensitive and dignified manner. A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. There are ongoing training courses to enable staff to meet individual service users needs and ensure they are protected from harm and abuse. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 6 The home is adequately staffed to meet the needs of individuals living at the home. What has improved since the last inspection? What they could do better: It would be better if all prescribed medicines are given to service users as prescribed as and advice is sought from the General Practitioner when needs change. Whilst generic risk assessments were undertaken in different areas of the home, it was agreed that the risk assessments must include the lounges and bedrooms. It is disappointing that this requirement, made at the last inspection, has not been met. The registered manager is reminded that failure to meet requirements may result to enforcement action being taken. A service user would be adequately protected if the risk assessment is put in place after falls and care plan reviewed to support staff in meeting the needs of this individual. Prospective service users and their families would receive accurate information if the Statement of Purpose and the Service Users guide are updated. Individuals living in the home would be adequately protected if the Gas and Electrical installations are checked regularly and in accordance with health and safety regulations. The home must ensure that fire risk assessment of the building is undertaken in order to protect the individuals living in the home, staff and visitors. Evidence of compliance to some of the requirements was received at the Commission before this report was completed. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 7 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. Charlton House 85 High Street DS0000003317.V359994.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 Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that service users are assessed before admission to ensure that their needs will be met. However a review of the Statement of Purpose and Service Users Guide is needed to provide accurate information to prospective service users and their relatives. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide. However these two documents have not been updated. This is to provide accurate and required information to prospective service users and their relatives when they visit the home or make enquiries to enable them to make an informed choice about moving into the home. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 10 The registered manager stated that these documents would be reviewed and copies sent to the Commission for Social Care Inspection. Updated copies of the above documents were received at the Commission before the report was completed. At a discussion with a recently admitted service user, the individual stated that they came to look round and was satisfied with the home. The person stated that they were made aware of a one-month trial period to enable them to decide whether to stay. The registered manager told us that the individual was assessed when he visited the home before admission to the home. There is evidence in the care file to confirm that this happened. Terms and conditions of their stay at Charlton House were noted in a file viewed. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers care and support to service users throughout their lives and towards the end. However it fails to protects service users by lack of risk assessments and care plan review. Furthermore medication administration practices are unsatisfactory and fail to protect individuals living in the home. EVIDENCE: We looked at all four care files at this visit. Records showed that one recently admitted individual had pre-admission assessment. There was evidence of individualised care plans, which described how these needs are to be met, and the care plans were recently reviewed. The home has an equal opportunity policy in place, to ensure that staff provide care to the service user based on individual needs and capabilities. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 12 The service users that we spoke with confirmed that their privacy was never compromised when staff assisted them with personal care. One individual stated that they were satisfied with their care. “It is a privilege to live here it feels so much like living in your own home” Staff were noted knocking at the service users’ doors and waiting for an answer before going in to assist service users with personal care demonstrating that individuals living in the home are treated with respect and that their privacy is maintained. However we looked at one care file of an individual with three recent falls. We noted that the person had no risk assessment put in place to help to minimise these falls. Furthermore, we noted that there was a care plan identifying that this person was prone to falls but this has not been reviewed following these falls. This is necessary so that staff can support and protect this individual from possible injury. We discussed this with the registered manager and it was agreed that the risk assessment must be put in place along with the care plan review in order to protect this person. There was evidence of visits from the Doctor, optician, chiropodist and other health professionals on the care files reviewed. Medication administration was reviewed and was noted unsatisfactory. Records show that the home has a medicine policy was in place, there was evidence of receipt and disposal of medication and these were properly recorded. Action has been taken to provide training about medicines for staff, and this is good practice to help staff administer medicines safely. A local pharmacy supplies medicines monthly using a blister pack monitored dosage system. Some records seen show that the medicines refused by service users have not been recorded in the Medication Administration Record Sheets and no reason for refusal was noted in the daily record. Medicines prescribed to be given regularly were given as ‘when required’. The registered manager stated that this was agreed with the doctor verbally but had not been altered or confirmed in writing to reduce the risk of medication errors happening. A requirement has been issued to remedy this unsatisfactory practice. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 13 The registered manager stated that she would contact the General Practioner to review the identified medication and would ensure that records of all refused medicines are clearly documented including the reason for refusal. We will be monitoring this at the next visit. There was evidence in the care files viewed of details of service users’ wishes in the event of death. One staff member that we spoke with showed awareness of policies and the procedure regarding dealing with a dying individual and at the time of death. The staff member was aware of the importance of keeping information about service users’ confidential. Charlton House 85 High Street DS0000003317.V359994.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home enables service users to maintain contact with family, friends and community. It also provides choice in respect of meals and mealtimes. Individuals living in the home are not provided with a meaningful choice of activities. EVIDENCE: On the day of this visit all the four service users were relaxing in the lounge and staff were noted interacting with them in an informal and personalised manner. At a discussion with the individuals in relation to how they spend their time during the day, one person stated that they go out sometimes for a walk another person stated “I just sit and watch television and read”. One individual also told us that a friend comes every Friday and that the family also takes him out sometimes. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 15 Whilst the individuals living in the home are not concerned about the limited activities provided in the home it would seem that the home is not implementing the statement noted in their quality assurance document which describes the activities to be provided at the home. We spoke to one relative on the day and the person confirmed that they are satisfied with the services provided at the home and the care of their relative however “our only concern is the lack of activities in the home”. People living in the home told us that staff supported them to maintain contact with their friends and families. The Home’s visitor’s book showed that there are a number of regular visitors to the Home. We looked at the menu and we observed that the menu contained only one choice at lunchtime. Individuals living in the home told us that they were very happy with the menu and would not want to change anything. The home would always provide an alternative if they were not satisfied with the food prepared for them. The meal for lunch-time on the day looked nutritious and balanced. It includes, cod in parsley sauce, creamed potatoes and peas followed by dessert. The kitchen is spacious and was found clean and tidy. Staff have attended basic food hygiene training and food hygiene certificates of staff were noted displayed in the kitchen. There was evidence of the fridge and freezer temperature recordings being completed daily. Food noted in the fridge was labelled to ensure that staff are aware of the foods’ disposal date. Records also evidenced that the food probe temperatures were being taken on a daily basis. The home undertakes a yearly food safety audit, which includes general hygiene, food preparation and storage, risk assessments, staff training and refuse disposal. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The service users are enabled to complain with the confidence that their views will be listened to and acted upon, staff receive appropriate training for protection of people from abuse. EVIDENCE: There were no recorded complaints seen since the last inspection. Evidence from staff and discussion showed that staff and individuals living in the home are aware of the complaints procedure. The complaint procedure was also displayed at the entrance of the home. A staff member spoken with stated that individuals living in the home are enabled to complain through good relationships and trust and understanding of their individual needs. People we spoke with told us at this visit that they had no complaints. We noted from the staff files reviewed that staff had received training on Protection of Vulnerable Adults from abuse. The manager stated that the home would normally obtain enhanced Criminal Record Bureau disclosure before employing any new staff member in order to protect the service users. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 17 No new staff members had been employed since the last inspection. Staff told us that they are aware of the whistle blowing policy to enable them to report any suspected abuse without fear of reprisal. The South Gloucestershire Policy and Procedure for reporting abuse of vulnerable adults was noted at the home and staff members spoken with demonstrated awareness of their responsibilities in relation to protecting people from harm and abuse. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,23,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users enjoy a pleasant, safe and homely environment where a good standard of hygiene is maintained to protect the individuals living in the home. EVIDENCE: Charlton House is a small privately owned Residential Care Home situated on the High Street in the village of Wickwar. It can cater for up to five elderly people. There are three single rooms and one double, a well-furnished lounge and dining room, and a large kitchen. The home is situated close to several small shops in the village. Large shopping areas are available several miles away in Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 19 Chipping Sodbury or Yate. The Home is close to the bus route for Chipping Sodbury, Yate, Bristol and Wotton-under-Edge. The house is situated in a terrace with the rear of the property overlooking a large patio and a well-established garden. There are seating areas available to service users in the garden. The home remains suitable for its purpose and was found to be clean, tidy and free from unpleasant odours. The corridor, staircase, bathrooms and toilets were fitted with hand and grab rails to assist with peoples’ mobility There were soap and hand towels located in the bathrooms and toilet facilities. The home is accessible, well maintained and is decorated to a high standard. The home is comfortable and homely. The home has appropriate laundering facilities situated away from where food is prepared. Service ‘ The Home has a policy and procedure for the control of infection, which includes the safe handling and disposal of waste. People living in the home told us that they felt safe at the home. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users are provided with sufficient numbers of staff to meet their needs, adequate training is also provided to staff to protect the individuals living in the home. EVIDENCE: There have been no changes in the staff team at the home since the last inspection. There is a small team at the home. The home has in place a code of conduct for staff and also a copy of the General Social Care Council codes of practice for care staff. The manager told us and there evidence of this in the staff file we viewed that there is one member of the care staff who has completed the National Vocational Qualification (NVQ) 2 in care award, with a local college. Two care staff training records were reviewed. There was evidence that staff have undertaken regular training in topics including ‘fire safety, ‘dementia training’, medication training ‘food hygiene’ and ‘protection of vulnerable adults from abuse’. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 21 The registered manager informed us that the staffing level is satisfactory and meets the needs of the people living in the home as confirmed by the current rota. Everyday from 8am to 1pm the manager and two carers are on duty. From 1pm to 4pm there are two staff members and from 4pm to 8pm there are two staff members. Mr and Mrs Addle cover the night duty as they live in the premises. The home would ensure that no new staff member is recruited in the home without appropriate recruitment documentation in order to protect the individuals living in the home. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, staff are supervised regularly. However the home fails to protect the residents through satisfactory health and safety practices. EVIDENCE: Mrs Addle is registered manager and owner and has been at the home since 1999. Mrs Addle has been a registered nurse for many years and has a range of experience in different settings. The registered manager has completed NVQ level 4 in care management. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 23 At this visit the registered manager demonstrated good knowledge of the care needs of the individuals living at the home. It was clear that a good relationship has been built with the service users and has been established for some time. This is supported by what one service user told us. The individual stated “Teresa is a nice person, she will always ask us what we want and try her best to provide it for us”. The registered manager, the proprietor and the staff member on duty all came across during the inspection as open, positive and committed to providing a quality service for those living at the home. The staff member on duty demonstrated a clear understanding of the individual needs of those living at the home and gave examples of how individuals are supported. The staff member said that although the staff team was a small one they all worked well together in order to ensure continuity of care for the individuals living in the home. Mrs Addle has introduced formal structured supervision sessions with staff. The supervision records of two members of staff seen showed that supervision sessions take place on a regular basis. One care staff we spoke with told us that they were appreciative of the supervision and support provided by Mrs Addle. The home has different ways of monitoring the quality of the services at Charlton House. These include review of care plans, service users, kitchen audits, staff supervision and staff training. The home also receives feed back from the General Practitioners (GP) and other health professionals visiting the home. We noted that some accidents were recorded but were not reviewed. There was no risk assessment in place to enable staff to support the individuals in order to protect them from further falls. A requirement was issued to ensure that this is remedied. The fire logbook record showed that the required weekly tests of the fire alarms were being carried out, and were up to date. The fire fighting equipment had been checked on a regular basis. However a fire risk assessment needs to be undertaken to ensure that people living in the home are adequately protected from fire incidents. Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 24 It was agreed that that the Gas inspection certificate and the Five Yearly Electrical Installation certificates must be forwarded to the Commission for verification. The Gas safety inspection certificate carried out on the 25/02/08 was received at the Commission before the report was completed. The manager told us that the 5 yearly Electrical Installation safety checks would be booked as soon as possible and that the certificate will be forwarded to the Commission on completion. The inspector discussed with Mrs Addle what sort of health and safety audits of the environment are carried out. Mrs Addle said she very regularly walks around the home and checks basic maintenance, and health and safety of the environment. We saw evidence that the home ensures as far as is reasonably practicable the health, safety and welfare of the service users and staff. Appropriate policies and procedures were viewed by the inspector and included, Control of Substances Hazardous to Health, Health & Safety Guidelines, Infection Control Procedures, Missing Persons policy and Death and Dying Policy and procedures. There is an up to date certificate of employers Liability Insurance at the home. Mrs Addle said no money or property is held by the Home on behalf of the service users. Evidence was in place to show that the stair lift for service users use was serviced by an appropriate contract on 11/02/08. The Environmental Health Department of South Gloucestershire Council visited the home in July 2007 and the home continued to maintain its food hygiene award. Service users records were well maintained, up to date, and in order. The care records were stored securely when not in use. General records relating to the day-to-day running of the Home were also well maintained up to date and in order. Charlton House 85 High Street DS0000003317.V359994.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 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13.2 Timescale for action The registered person shall make 22/03/08 arrangements for the recording handling, safe keeping, safe administration and disposal of medicines received into the care home: Records must be kept of medication refused by the service user including the reason for refusal. Medicines must be administered as prescribed by the doctor. Service user risk assessment must be put in place and reviewed after falls to minimise accidents. Care plans must be put in place and reviewed following falls to meet the needs of identified individuals. Undertake fire risk assessment of the home to ensure that people using the service are adequately protected. Requirement 2 OP7 13 15/03/08 3 OP7 15 15/03/08 4 OP38 13 22/03/08 Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 27 5 OP38 13 6 OP38 13 7 OP1 6 Undertake a generic risk assessment of all areas the service users have access to including the lounge and bedrooms. Ensure that five yearly electrical installation safety checks and servicing of Gas boiler are undertaken to protect the individuals living in the home. Ensure that the Statement of purpose and Service users are reviewed to provide prospective service users updated information about the services provided at the home. 22/03/08 22/03/08 22/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Charlton House 85 High Street DS0000003317.V359994.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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