Inspection on 21/04/05 for 33 Charnhill Crescent

This inspection was carried out on 21st April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

33 Charnhill Crescent 02/02/07

33 Charnhill Crescent 10/11/05

33 Charnhill Crescent 02/12/04

33 Charnhill Crescent 13/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Charnhill Crescent, 33 Mangotsfield South Glos BS16 9JU Lead Inspector Odette Coveney Unannounced 21 April 2005 09:30 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 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. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Charnhill Crescent, 33 Address Mangotsfield South Glos BS16 9JU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 3774018 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust Ms Janice Griffiths Care Home for Older People 4 Category(ies) of MD Mental Disorder registration, with number MD(E) Mental Disorder -over 65 of places Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate persons aged 19 years and over requiring personal care Date of last inspection 2-Dec-2004 Announced Brief Description of the Service: Charnhil Crescent is a care home registered with the Commission for Social Care inspection to provide accomodation and personal care to four adults with mental health problems. The home is a detached, corner house in a residential area and has well tended gardens on all sides of the property. The home is a short walk from all local amenities. It is close to a main bus route to Bristol and is also very close to the Avon ring road. The home was originally registered to provide a service for five adults, however some time ago this was reduced to provide a home for three people. Within the last six months there has been a new admisssion to the home, making the number of those acccomodated at Charnhill to four. The home has a first floor bathroom and a ground floor shower room with a separate toilet. The kitchen is well equiped and offers space for supporting individuals to maintain their independence. There is a small office area on the ground floor which also houses the washing machine and a tumble dryer. The home is in good decorative order and well furnished. Those living at the home, with the exception of the most recently admitted person to the home, have chosen the way in which their rooms are decorated. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the two requirements and one recommendation from the last inspection that was conducted in November 2004. The inspection took place over six hours. During the process three residents, a support worker and both of the registered managers were spoken with. The inspector looked around some of the building and examined records. What the service does well: What has improved since the last inspection? A recommendation was made at the previous inspection that the home review staff training information held in order to ensure that sufficient, correct information is held, this was reviewed at this inspection and the information seen on staff training had been well recorded. There have been some improvements to the décor since the last inspection; a toilet and shower area has been redecorated, therefore ensuring the home continues to be well maintained. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 6 There has been one admission to the home since the last inspection, all of those affected by the process have been well supported and listened to. Information in order to support the individual had been written in a person centred way with the individual central to the admission process. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 7 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 Standards Statutory Requirements Identified During the Inspection Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. Information is available to residents and their representatives about the home and the admission process provides adequate safeguards however, not all resident’s are issued with a contract. EVIDENCE: The statement of purpose and a leaflet providing information about the home was available to resident’s, these were in need of minor updating and will be reviewed at the next inspection. Guidance on care provision, staffing qualifications/skills and special needs catered for, however not all resident’s were provided with a contract. Care management and health need assessments were seen on file. The home has developed comprehensive care plans from the information provided by the resident’s and information gathered during the assessment process and during the trial period. The most recently admitted resident to the home told the inspector that they had personally found the transition from hospital to a residential setting quite difficult, however they said that staff had taken time to explain processes to them, that they had visited the home prior to admission, that they had stayed Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 9 at the home for a trial period and that during that time staff had asked for their views and had been listened to, that their wishes had been acted upon and they believed that “staff have my best interests and safety at heart”. The most recent resident to the home did not have a written and costed contract of service in place the contracts for the other three service users had not been updated or reviewed since September 2003. The management team demonstrated care is provided on current good practice, and reflects specialist guidance focussing on the needs of those with mental health problems. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11. Care is provided in a risk assessment framework; ensuring resident’s rights, dignity and healthcare needs including medication are well met. EVIDENCE: The health needs of resident’s are well met with evidence of good multi disciplinary working taking place on a regular basis. Resident’s told the inspector that they were well supported in areas of their health care and provided clear examples of this, one resident told the inspector that staff were supportive to them, that they provided encouragement and guidance, the individual also told the inspector that choices they have made had been respected by staff. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 11 Records in place confirmed information told to the inspector by resident’s and staff and recorded that residents remain well supported with all aspects of their emotional and healthcare requirements. Records detailing all aspects of healthcare needs were well ordered and included specialist input such as psychology, psychiatrist, optician, district nurse and general practitioner. Care plan information in place was detailed and provided evidence that residents had contributed to the information in place, recorded were their strengths, needs, likes and dislikes. Individual routines and choices were recorded. Residents told the inspector who their key worker was and gave examples of how they are supported with aspects of their life both within and external to the home. Job descriptions were seen by the inspector; these were comprehensive and covered all aspects of staff role and responsibility, staff members spoken with demonstrated knowledge and understanding and told the inspector that those living at the home are treated as individuals, with the dignity and respect they are entitled to. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15. Social activities and community presence are well managed, and are tailored to the specific wishes and abilities of the individuals, these were creative and provide daily variation and interest for the people living in the home. EVIDENCE: Information seen by the inspector, and confirmed by Ann Street, and resident’s showed that those living at the home are offered a variety of social activities. Resident’s are able to participate or not, this is dependent on the individual’s choice. At the time of the inspection one of the resident’s was on holiday with a relative. During the inspection the manager and key worker consulted with a resident to confirm the arrangements made for their holiday to Weymouth later in the year. All of the resident’s spoken with provided clear examples of how they are supported to take up employment, participate in community based activities and maintain relationships with their friends and family. Daily records showed that resident’s had been consulted and following discussion support given to complete application forms for employment, prospectuses had been requested for further education, and items purchased in order that individuals are able to pursue their hobbies and interests. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 13 Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints system in place with some evidence that resident’s feel their views are listened to or acted upon. EVIDENCE: All resident’s spoken with told the inspector that if they had any cause for concern or complaint they would speak to one of the managers for the home. All of those spoken with said they had no complaints. Policies and procedures are in place to minimise the risk to resident’s from any form of abuse. A staff member told the inspector of the comprehensive protection of vulnerable adults training that they had undertaken and how this knowledge provided additional insight into their role and responsibilities. No complaints have been received by either the home or the Commission for Social Care Inspection. No resident’s users at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, Following recent investment the standard of the environment has improved and has created an attractive and homely place in which to live. EVIDENCE: The home is well furnished and maintained to a standard that creates a comfortable ambience. Since the last inspection that was undertaken in November 2004 a ground floor toilet area and also a shower area have been re decorated. Both the residents and staff confirmed that the service users room is the next priority for redecoration and that the individual whose room it is will be fully consulted. All areas of the home smelled pleasant and were cleaned to a high standard; this has been noted on previous visits. One room that was formally used as an office is now being utilised as a resident’s room for the most recently admitted person to the home; it was clearly evident that the décor in this room had not received any attention for a Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 16 number of years and although this does not pose a risk to the resident it does not provide a pleasing environment in which to live. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28, 29,30 Whilst there is a high level of support from management for the stable staff team that is enthusiastic and works positively with residents, staff records are not complete. EVIDENCE: Discussion with the management team, staff and resident’s provided evidence that regular supervision sessions are held and appropriate agenda items are discussed in order to inform and direct staff. Staff members spoken with confirmed a high level of support and training appropriate to the tasks they had to perform. Resident’s spoken with said that they felt well supported and safe, that staff listened to them. Those spoken with did not raise any concerns about the staff levels at the home. All staff records were examined and although some progress had been made to hold staff recruitment documents on the premises it was evident that all of the documents as outlined within the schedule two were not in place, therefore the requirement made at the previous inspection has not been met and will be further reviewed at the next inspection. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38 The managers support each other and the staff team and while the robust policies and procedures in place aim to protect them and resident’s this is compromised in that they have not been reviewed and staff have not received sufficient fire safety awareness. EVIDENCE: The registered managers are able to provide a clear sense of direction, and had strategies in place to ensure staff develop the skills and expertise to undertake the tasks they are to perform. Both managers have completed the NVQ level 4 and they demonstrated through the inspection process a commitment to providing a high standard of individualised care. One of the managers is a mentor to social work and nurse students, the other manager is an assessor for those staff undertaking NVQ at level three, promoting independence. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 19 Jan Griffiths told the inspector that there are no staff currently going though the disciplinary or capability procedure within the home. Records reviewed were kept secure in the office, which could be locked when not in use. The records were generally satisfactorily maintained, up to date, legible and in order. The organisation has very clear policies and procedures in place that cover all aspects of the service, resident’s rights, and staff role and responsibility, however the documents in place still refer to the previous organisation which ceased to exist over two years ago, Jackie Mules told the inspector that she is part of a working party that is reviewing the organisation’s policies and procedures and forwarding their findings to senior management, it is recommended by the inspector that the headings are changed in order to reflect current Trust status. The fire logbook and staff training records evidenced that staff have not received sufficient training instruction. Strategies to overcome this were discussed with the management. Staff must receive appropriate instruction in order that they are competent to deal with fire emergencies and evacuation. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 3 3 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 N/A N/A 3 2 2 Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 37 Regulation 26 Requirement Timescale for action 21/06/05 2. OP 29 19(1)(b) 3. 4. OP 38 OP 2 23(4)(d) 5(b) It is required that regulation 26 reports are legible and contain more detail to provide a clear overview of the day to day issues that are discussed and identified during the monthly visits to the home Staff records as detailed in 21/05/05 schedule two, are to be held on the premises and be for inspection. Staff to appropriate sufficent 21/05/05 fire safety instruction. Terms and conditions to be in 21/05 place for all service users; those in place to be reviewed to ensure information held is correct. 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 OP 24 Good Practice Recommendations Newly admitted service users room to be redecorated relfecting the taste and choices of the service user. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 22 2. OP 36 Organisational policies and proceedures to be updated in order to reflect the current status. Charnhill Crescent, 33 CS0000003358.V201889.R01.doc Version 1.20 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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. 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