Inspection on 12/09/06 for Chargrove Lawn

This inspection was carried out on 12th September 2006.

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

Chargrove Lawn 04/06/09

Chargrove Lawn 09/06/08

Chargrove Lawn 13/08/07

Chargrove Lawn 30/01/06

Chargrove Lawn 15/08/05

Chargrove Lawn 14/03/05

Chargrove Lawn 05/10/04

Chargrove Lawn 22/03/04

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 Chargrove Lawn Shurdington Road Cheltenham Glos GL51 5XA Lead Inspector Mrs Ruth Wilcox Key Unannounced Inspection 12th September 2006 13:00 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 Chargrove Lawn DS0000016401.V303779.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. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chargrove Lawn Address Shurdington Road Cheltenham Glos GL51 5XA 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) 01242 862686 F/P 01242 862686 CTCH Ltd To be appointed Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Chargrove Lawn is a care home registered to provide personal care for 26 older people over the age of 65 years. In cases where nursing care is needed, it is accessed from community sources. The home is part of the CTCH Ltd group of homes and is set in a semi-rural location on the outskirts of Cheltenham. The home has been adapted from a large domestic residence and has two purpose built extensions. Single rooms are provided throughout. All rooms have en-suite toilets but eleven also have en-suite bathrooms. The home is arranged on two floors with a shaft lift providing access to the first floor. There is a large amount of communal space for residents use including three lounges, one of which includes the dining area, and there is a garden room adjacent to the hairdressing salon. One of the smaller lounges provides an area where smoking is permitted. There are gardens to the side and rear of the property with patio area and garden furniture. A ramp allows easy access for people who use wheelchairs. Information about the home is available in the Service User Guide, which is issued to prospective residents, and a copy of the most recent CSCI report is available in the home for anyone to read. The charges for Chargrove Lawn range from £445.00 to £495.00 per week. Hairdressing, Chiropody, Newspapers, Toiletries and Transport are charged at individual extra costs. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector carried out this inspection over two days in September 2006. A check was made against the requirements that were issued following the last inspection, in order to establish whether the home had ensured compliance in the relevant areas. Care records were inspected, with the care of three residents being closely looked at in particular. The management of residents’ medications was inspected. Eight residents were spoken to directly in order to gauge their views and experiences of the services and care provided at Chargrove Lawn. A selection of staff were interviewed. Survey forms were also issued to a number of residents, visitors and staff to complete and return to CSCI if they wished. 60 of resident and 40 of relatives’ surveys, and 10 of staff surveys were returned. Some of their comments feature in this report. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and provision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. What the service does well: Chargrove Lawn provides a clean, well presented and very homely environment for the residents living here. Residents are admitted on the basis of an assessment, so that they can be assured the home can meet their individual needs. They have access to a good Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 6 degree of pre-admission information about the home, and can visit to view the facilities before making their final decision about moving here. Assessment information goes on to form the basis of clearly written and detailed plans of care for each person, which give clear direction for staff when delivering care. Each resident is afforded good access to health care services, with appropriate medical interventions when required, to assist in meeting their health needs. Residents are satisfied with the standard of care they receive at this home, and the way in which it is delivered, with evidence that individuals’ privacy, choices and diversity is respected. The home has an inclusive atmosphere for visitors, with relatives indicating that they feel welcome here, and that they are consulted and kept informed appropriately. There is a robust system for addressing complaints should any arise. The food served is of a good standard, and residents themselves said that they enjoy their meals. Staff have good access to training opportunities, and are making good progress with the National Vocational Qualification (NVQ) training programme. Recruitment is carried out using rigorous employment procedures, with new staff appropriately supervised. The home offers a safe and transparent system for safeguarding personal monies or valuables for those residents wanting such a service. What has improved since the last inspection? A new manager has been appointed to this home. He is providing good leadership to staff, and assurances for residents and visitors. He is providing a focus on identifying areas for improvement, and has made some good progress to date in this regard. Chargrove Lawn’s information brochure now includes a printed insert, which ensures that any reader is well informed regarding access to CSCI reports about the home. Residents’ care plans have been improved, to include full and very informative detail about each person’s medication regimes. Their nutritional needs are also more comprehensively assessed now, with the introduction of a new assessment tool; this has resulted in any risks being identified, with prompt corrective actions undertaken where needed. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 7 Since the last inspection specific time has been allocated to staff in order that they may spend more quality time with residents on a one to one basis, either carrying out key worker tasks or in a social sense. There is a much improved system for planning and recording staff training, with a revised and more frequent training programme becoming more available. Improvements in the environment include a new dishwasher, new armchairs, hand washing facilities in the laundry room, and new washable flooring outside the laundry and kitchen. What they could do better: The management of residents’ medications is generally satisfactory, but some isolated improvements are required on this occasion, which pertain to recording and stock control. The home has failed to comply with a statutory requirement to replace the laundry room flooring within the permitted timescale; however assurances have been given that this work is to be carried out very soon after this visit has taken place. Although new workers in the home are quite correctly allocated a supervisor to work alongside them during their induction period, it would be an improvement if the home were to clearly identify the supervisor responsible for this, as it can change from time to time during the period. The home needs to assess the risks posed to residents by the open water in the garden’s small fish pond more closely. Although there is evidence that staff are available and attentive to residents, the home needs to remain alert to the possibility of non-care tasks allocated to the care team each day having an adverse impact on time spent with the residents. To date, the home has failed to ensure that the fire safety systems are serviced by an appropriately qualified person; the home’s own maintenance man is carrying out this work. Also, the home needs to consider the manufacturers’ instructions when carrying out servicing and maintenance of the variable height bath. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 8 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. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 9 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 Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 1, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough assessment process plus the provision of literature and other information about the home, enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. EVIDENCE: Written survey responses from residents or their relatives confirmed that they had had access to information about the home prior to their admission. A copy of the Service User Guide is issued to each prospective resident, and this brochure now contains an insert, which clearly informs the reader about access to CSCI reports about the home. A copy of the last CSCI report was easily visible in the home’s reception. A copy of a pre-admission assessment carried out on a prospective new resident had been conducted and recorded in full before their admission to the home was agreed. A copy of a letter from CTCH Ltd confirming the admission was on file. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 11 Appropriate care assessments and health information from other health care professionals involved in the case were also on file. This person had also been enabled to visit the home, look around and view the available room, and also stay for lunch with the other residents. Chargrove Lawn does not provide intermediate care. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive care planning system in place, which can provide staff with the information they need to satisfactorily meet residents’ health and personal needs. The systems for the administration of medications are mostly satisfactory and provide appropriate safeguards for residents when consistently applied. In the main care is offered in such a way as to meet residents’ needs in respect of their privacy and dignity. EVIDENCE: A lot of work has been carried out and is still being carried out at this time to improve the standard of care planning documentation. All residents have a recorded plan of care that clearly links to a very detailed individual assessment of their health and personal needs; plans are regularly reviewed. Three were chosen for closer scrutiny as part of the case tracking exercise. Care plans contained clear instructions for staff to follow when delivering both personal and health related care. Planning took into account residents’ Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 13 personal preferences, privacy and levels of independence. Recorded reviews of care plans reflected outcomes from the resident’s own point of view. Each plan contained appropriate risk assessments, such as for risk of falls, pressure sore vulnerability, nutrition and moving and handling, and there were associated care plans documented accordingly to address any risks identified. For those with a risk of developing pressure sores, appropriate healthcare intervention and support equipment was in place. There are records of regular weight monitoring for each resident, and comprehensive nutritional assessments. The manager has done well to introduce a new assessment tool for this purpose; The Malnutrition Universal Screening Tool (MUST). Care plans on this basis are detailed and informative to address any areas of concern; they incorporate medical referrals and the introduction of additional nutritious snacks and/or supplements where necessary. Records show that the residents are afforded regular medical reviews and consultations, and access to a range of health care services, either in the community or in the home. Care was being delivered in accordance with the care plans, and when interviewed, staff were able to demonstrate their understanding and awareness of individuals’ needs and their planned care. There are now detailed care plans focussing on individuals’ medications, which provide valuable information for staff in this area. Residents are able to self-medicate if they wish and are able; this is done on the basis of a documented risk assessment for the individual. There are printed Medication Administration Records from the supplying pharmacist, which staff have to be particularly vigilant with to check for accuracy, as the supplying pharmacy has a tendency to print certain items more than once on the chart; this is despite regular requests by the home to correct it. There are plans to change the supplier in the near future. A number of hand written entries on charts had not been signed in full by the author, and there was no second signatory as a witness in other cases. In cases where a medication is prescribed on an ‘as required’ basis, there are clearly written protocols for their usage. Storage of medications is safe, with appropriately detailed records for receiving, disposal and management of all types of medication. Boxed and bottled items are dated on opening so as to protect against using the item beyond its expiry date; however one liquid item was in still in stock, despite expiring some weeks ago. The home has access to reference material, and staff involved in the management of medications have received the necessary training from a local college. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 14 Residents themselves spoke positively about the care and staff in the home. One lady said that she always received very prompt medical attention when she needed it. All, bar one, felt that staff were respectful, kind and caring. This one person’s concerns are the subject of regular attention from the manager. Written survey responses also confirmed residents’ and relatives’ satisfaction with standards of care, with one actually saying that there was ‘excellent care and support here’. One person said that his privacy is generally respected, but that sometimes the staff do just ‘knock and whiz in’. Staff were observed whilst interacting with residents, and each was seen being courteous, polite and caring. Staff have received training in core values, incorporating respect for diversity, privacy and dignity for residents, and care planning is also very mindful of these issues. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes efforts to ensure that the opportunity to engage in social activities is offered to all residents, and that they can exercise choice in their daily lives. Visiting arrangements are such that residents can keep close contact with their families and friends. Dietary needs are well catered for, with a selection of food available that meets residents’ tastes and choices. EVIDENCE: Residents’ assessments indicate whether they are interested in activities, and there is also reference to individuals’ religious preferences. A programme of social activities is devised each month; the current one shows activities that will meet both more active and quieter needs as well. There are regular trips and outings planned, with parties and social gatherings a regular feature. Some residents said that their choice not to participate in group activities was always respected, their preference being to read, watch television or listen to music alone. Large print library books are provided. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 16 A game was taking place during the afternoon, but there were certainly times when numbers of residents were sitting unattended whilst staff went about other tasks. One lady said that she ‘gets fed up sitting’. The manager has introduced an allocation system that ensures that staff spend more social time with residents, whether this be in group activities, or on a one to one key worker basis. The manager is also considering ways to broaden the range of activities on offer for residents. Relatives and friends of residents are very welcome here, and are invited to join in the life of the home, including socially. Residents confirmed that their visitors are always made to feel very welcome, and can visit at any time of theirs or their relatives’ choosing. One resident did not have a second chair in her room, and requested to have one for her visitors. One particular resident was extremely grateful for the way in which the home welcomed their friend, and for the respect and understanding that is shown towards their lifestyle and choices. Written survey responses from relatives all confirmed that they feel welcome here, and that they consider the home consults with them and keeps them appropriately informed. Just one response indicated a reservation about the consistency of a good standard of care in the past for their relative. Residents’ choices are respected generally, with many personal influences noted in individual bedrooms, with the provision of different meals according to choice as well as need, and with those who were freely moving around the home. Two residents said how much they appreciated their independence, and how staff respected this. Two others said that they ‘did as they liked’, with one of these saying that she had made this quite clear to staff. Advocacy information and leaflets from advisory services were available in the hallway for those who might be interested in this. The home is not involved in the management of any residents’ affairs, with residents being independent or having their own representatives to assist them where needed. The service of a breakfast meal and lunchtime meal was seen. The majority of breakfast meals were served on trays in residents’ bedrooms. For lunch, the dining room was laid very attractively, with condiments, napkins, drinks and flowers. The cook served lunch according to individual’s choices from a trolley, a list of which is compiled each day and given to the cook for her reference. The cook is also very well informed about individuals’ dietary needs. The day’s menu is displayed; the manager is planning to review the menus with the cook in the near future. There are very clear assessments and monitoring systems in place for those nutritionally at risk. One lady with partial sight needed the items and each Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 17 position on the plate pointed out to her, so that she could manage independently. Residents confirmed that the quality and quantity of food is very good, either in conversation or through written survey responses; one said there are ‘excellent and varied meals’, with another saying that it could be ‘variable’. Snacks are readily available in the home, with a selection of sweet items and fresh fruit provided at all times. The kitchen was clean and orderly. A ‘kitchen diary’ as a means of recording necessary catering related issues, such as high risk food, refrigerator and deep-freeze temperature checks has been implemented; cleaning tasks carried out each day are also recorded here. A new dishwasher has been installed since the last inspection. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 18 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 the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system, with evidence that residents feel that any concerns they may have are listened to and acted upon. The home’s Adult Protection policies help to provide a safe environment for the residents. EVIDENCE: All written survey responses, with one visitor exception, said that they were familiar with the complaints procedure should they need it; the procedure for dealing with complaints is clearly displayed on the home’s public notice board. The home has not received any complaints recently. Residents surveyed said that they had confidence in the staff to listen to and act upon any concerns raised, with one writing that the staff were very obliging. Residents spoken to were particularly appreciative of the new manager’s helpful approach towards them. One person said that the staff and the manager attend very promptly to concerns they might raise, with others confirming that staff and manager do all they can to help deal with issues and concerns as they arise. The home has written policies and procedures for the protection of the vulnerable residents, although this should be reviewed as it currently reflects some detail that is incorrect, such as the details of the regulatory body and the named contacts within the Adult Protection Team. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 19 Staff have received instruction in adult protection issues. However there is currently an increased emphasis in this area, with a new and updated adult protection training programme being implemented for the staff this month. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 20 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 the following standard(s): 19 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is satisfactory, and provides residents with a comfortable and clean place to live. This outcome group would have achieved a good quality rating had the home complied with a previously issued statutory requirement timescale regarding the laundry flooring. EVIDENCE: The home has a maintenance person, who works across all the homes in the group. Records of all maintenance carried out are kept. Chargrove Lawn provides a very pleasant and homely environment for the residents living here. It is spacious, clean and satisfactorily decorated throughout. Redecoration and attention to maintenance issues is carried out as part of an ongoing programme, and there are two bedrooms that are in need of some Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 21 urgent attention, one of which was odorous, and the en-suite shower trap was dirty; these particular rooms are already prioritised in this regard. The corridor lighting is slightly dim. There have been a number of improvements in the home, with the provision of new, variable height armchairs, and alterations to the layout of the communal lounges that are more in line with residents’ comfort. There are pleasant surrounding grounds, with the home being a ‘Cheltenham In Bloom’ winner, for its lovely garden displays. The home is clean and fresh, and there is liquid soap, paper towels, sanitising hand-gels, gloves and aprons as part of infection control protocols. A new, washable floor covering has been fitted outside the laundry room and kitchen. Hand washing facilities have now been sited within the laundry room, and this is a very positive improvement; a liquid soap dispenser and paper towels have yet to be provided with it though. Laundry is handled appropriately, with due regard to infection control measures for foul items. One resident said the standard of the laundry service has recently improved, with previous problems of items not being returned resolving. The home has failed to comply with the requirement to replace the flooring in the laundry room within the timescale, however assurances were given that this is being addressed next week. There are also plans to tile the laundry room walls, which will assist with infection control measures in terms of ease of cleanliness. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. 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. Staffing provision is adequate to meet the needs of the residents currently living in the home. Robust recruitment procedures ensure that suitable staff are employed for the protection of residents. The arrangements for the induction and training of staff are good, with the staff able to learn the skills necessary for their role. EVIDENCE: A staff rota is maintained, and this allows for three carers to be on duty during all daytime hours, with one waking and one sleep-in carer on duty overnight. An ancillary team of cleaning, catering and maintenance personnel supports the care team. The manager works in a supernumerary capacity. The rota identifies the different tasks allocated to each worker on each shift, such as key worker tasks, and assisting with social activities. The deputy manager said that this introduction had been received well by staff. Care staff have a number of non-care related duties, and are involved with a small number of cleaning jobs and laundry. Written survey responses indicated that people feel there are sufficient staff on duty in the home, with confirmation that staff are readily available when they need them. Residents themselves spoke positively about staff, with just one exception who felt that ‘some were better than others’. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 23 The home is making good progress towards achieving the target of having at least 50 of care staff qualified to NVQ level 2 standard as a minimum. There are currently six staff qualified to at least this level, and there are a further 3 staff on the programme. Although the home does not yet achieve the standard of having at least 50 of care staff qualified, this is likely to be achieved in the near future given the current training provision. There has been one new staff member recruited since the last inspection, and this file was chosen for inspection. The record contained a completed application form, and a record of an interview. There appeared to be a possible discrepancy between the declared employment history and the dates provided on a reference; the manager resolved to follow this up. Full evidence of the required pre-employment checks was seen in the file, although the actual returned CRB disclosure was not seen directly on this occasion, as it is held at the CTCH Ltd head office; this will be inspected separately. There have been improvements since the last inspection in the way in which training records are maintained; there is now a formal matrix that shows each staff member’s training either undertaken, or required and planned. Records show a range of mandatory and optional training for all staff that pertains to their work. It is to the home’s credit that the manager is working in conjunction with another home manager in the group to increase and consolidate the training programme; this will provide staff with more frequent training days on a variety of subjects on the basis of developmental requirements. New care staff, who have had no previous experience, attend a structured induction programme with an external training provider, in addition to completing an in-house induction period. The induction record for the new worker showed the identity of the supervisor allocated to mentor them during their induction period. This supervisor does not always work directly with a new worker during this period, and another experienced carer is allocated to do this; on these occasions the identity if this person is not identified anywhere as a matter of record. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite some good management systems within Chargrove Lawn, there are certain aspects of health and safety management that are not robustly addressed by CTCH Ltd, which consequently does not consistently ensure safeguards for the health and safety of the residents; it is only this that has meant that this outcome group is judged as adequate and not good. EVIDENCE: There is a new manager at Chargrove Lawn. The manager has not yet been registered with CSCI for his role, and an application to address this is expected in the immediate future. The manager has a Certificate in Management studies, and confirmed that he had achieved the Registered Manager’s Award in another county. He is planning to undertake the NVQ level 4 in Care Award. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 25 Staff and residents all spoke very positively about the new manager, and the impact he has made in the home to date since his arrival. The manager is accessible to residents, visitors and staff at all times. He has been prioritising areas for improvement in the home, and has done well in his pursuit of issues raised on previous CSCI inspection reports as part of his intention to drive improvements here. There are a number of tools available in this home for assessing and monitoring quality standards in this home in terms of internal audits, although these have not been consistently applied and still are not. However, the new manager has given residents the chance to provide feedback on their views of the services in their home, and has produced a report on this basis, which highlights any areas of strengths and weaknesses for attention. The manager has plans to devise a resident survey that will centre around the CSCI outcome groups, and it is to his credit that he showed an interest in the Regulatory Lines of Assessment criteria used by CSCI in its assessment of the home’s performance as a means of driving improvements here. The manager has also invited relatives, friends and other visitors to the home to join a ‘Relatives’ Forum’; he sees this as another means of seeking views, sharing ideas, and giving those who live in and visit the home to have a say in how it can be run in the best interests of the residents. Some residents have placed personal money with the home for safekeeping. Clear and transparent records for each person, which include transaction details, running totals, and receipts, are kept. A random audit trail on a resident’s money in relation to their record proved to be accurate. Residents or their representative can sign to acknowledge some transactions, but where this is not possible in nearly all cases at this time, two staff members sign the record to witness on behalf of the resident. The safety of equipment in the home is reviewed under servicing agreements, and up to date certificates are in place for the lift, gas and electrical equipment. Hot water temperatures at outlets accessible to residents are regularly checked, and are generally maintained at a safe level. There is a pond in the rear garden of the home, and although this does feature in a documented risk assessment, the risks this open water might pose to residents must be reviewed and considered more closely. A fire risk assessment has been conducted. The training needs of the staff are now to be identified on the basis of individual need, rather than the ‘one size fits all’ approach that has previously been adopted. The fire alarm system and emergency lighting is regularly checked, and staff have received fire safety training. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 26 A Fire Officer inspection some months ago identified some concerns in the home, some of which have been addressed, but one of which has not. This related to the need for an appropriately qualified engineer to service the fire safety systems annually; at present a member of the maintenance staff who is not so qualified is carrying out this work. This concern will be addressed separately to this visit. There are no lifting hoists currently in use in the home, although there is a variable height and position bath, which can be raised, lowered and tipped according to need; a member of the maintenance team checks this piece of equipment. There are no servicing records for this, and it is not clear whether any checks carried out are in accordance with the manufacturers’ recommendations regarding the bath’s maintenance. Care staff have undertaken training in First Aid. Accident records are maintained, with regular auditing carried out; the manager plans to review the records currently used. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 27 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X 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 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 28 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) Requirement The Manager must ensure that staff sign any handwritten entries made on medication administration charts are signed in full by the author. The Manager must ensure that medication stock controls are carried out in a way that will ensure that all items are checked for date of expiry more robustly. The Registered Person must replace the flooring in the laundry room, to prevent any infection control risks. This requirement has been repeated from the last inspection. The Registered Person must provide CSCI with written confirmation of the manufacturers’ instructions for the maintenance of the variable height bath, and of how this has been taken into account as part the safety checks carried out. The Manager must ensure that the risks posed to residents by the open water of the garden pond are re-assessed, with DS0000016401.V303779.R01.S.doc Timescale for action 31/10/06 2 OP9 13(2) 31/10/06 3 OP26 13(3) 31/10/06 4 OP38 23(2.c) 30/11/06 5 OP38 13(4.a) 31/10/06 Chargrove Lawn Version 5.2 Page 29 actions taken to reduce any risks identified and taken. 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 2 3 4 5 Refer to Standard OP9 OP18 OP19 OP28 OP30 Good Practice Recommendations A second person should sign as a witness to any handwritten entries on medication administration charts. The written adult protection procedures should be updated to reflect the correct details of the regulatory body and the named contacts within the Adult Protection Unit. The level of corridor lighting should be made brighter. There should be at least 50 of care staff qualified to at least NVQ level 2 standard. The home should identify the named supervisor for new workers on their induction programme, and/or the staff rota for the duration of their induction. Chargrove Lawn DS0000016401.V303779.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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