Inspection on 24/08/07 for Charlesworth Rest Home

This inspection was carried out on 24th August 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charlesworth Rest Home 04/07/06

Charlesworth Rest Home 24/11/05

Charlesworth Rest Home 01/06/05

Charlesworth Rest Home 21/01/05

Charlesworth Rest Home 18/08/04

Charlesworth Rest Home 10/09/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Charlesworth Rest Home 37 Beaconsfield Villas Brighton East Sussex BN1 6HB Lead Inspector Judy Gossedge Key Unannounced Inspection 24th August 2007 11:00 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 Charlesworth Rest Home DS0000014190.V345574.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. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlesworth Rest Home Address 37 Beaconsfield Villas Brighton East Sussex BN1 6HB 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) 01273 565561 01273 565561 barry@bhorne9.wanadoo.co.uk Mrs Eileen Margaret Horne Mrs Eileen Margaret Horne Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is eighteen (18) Service users must be older people aged sixty-five (65) years or over on admission 4th July 2006 Date of last inspection Brief Description of the Service: Charlesworth is registered to care for up to eighteen older people who do not require a high level of care. The home is situated near to the Preston Park area of Brighton and consists of a large double fronted semi detached Victorian house. Accommodation comprises of fourteen single bedrooms and two double bedrooms, which are located over three floors. None of the bedrooms provide en-suite facilities. A passenger lift is available to the first floor only. The home would not be particularly suitable for wheelchair users and those with extreme mobility conditions. The home has a pleasant rear garden that service users enjoy during the warmer months. The home is located in a residential area of Brighton and is close to local transport, parks and other local amenities. The home’s Statement of Purpose and Inspection reports are available to view in the home. The service provides prospective service users with a copy of the Service Users Guide as part of the pre-admission process. The current fees are £368.00 per week with additional charges for hairdressing, toiletries, chiropody and newspapers. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours on 24 August 2007. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home, which has been completed and returned and information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Seventeen service users were resident and three service users were spoken with individually in their bedroom and a number were spoken to as part of the Inspection process in the communal area. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal area. Ten service user surveys were sent out and all came back completed. One new care worker who works during the day and at night and is the activities co-ordinator; two care workers one of whom also provides domestic support, the deputy manager and the Registered Manager were all spoken with. Five relatives/visitors surveys were sent out and four came back completed. What the service does well: What has improved since the last inspection? Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 6 The home has an assessment tool to record prospective service users initial care needs. The complaints policy and procedure includes a twenty-eight day response time. The quality assurance programme includes feedback from relatives and visiting professionals. What they could do better: 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. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is detailed information available for service users and/or their representatives to view, and potential new service users are individually assessed prior to an admission to ensure that their care needs can be met in the home. EVIDENCE: The AQAA detailed that on admission a copy of the Statement of Purpose and Service Users Guide is provided to prospective service users. The Statement of Purpose was viewed and should be updated and ensured that it contains all the required information. The Service Users Guide was not available to view during the Inspection. This was discussed with the Manager who confirmed that it would be ensured that both documents are up-to-date so a Requirement has not been made on this occasion. All the ten service users surveys stated they had received enough information and comments received were, ‘ plenty of Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 9 information,’ ‘I visited prior to moving in,’ ‘lots of helpful information,’ ‘very helpful information I received,’ and ‘extreemly helpful.’ The AQAA detailed that a formal recorded assessment has been introduced and is now completed prior to any admission to ensure individual service users care needs can be met in the home and to provide staff with information on the care to be provided. Two new service users documentation was viewed, who had been admitted to the home since the last Inspection and both had a copy of an initial assessment, although these should be signed by the person completing the assessment and dated. Intermediate care is not provided at Charlesworth. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by a detailed individual plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care, which needs to be provided and with supporting risk assessments completed. Medication policies and procedures are in place. EVIDENCE: Five of the service users individual care plans were viewed. These were detailed and gave clear guidance to staff of the care to be provided, service users health care requirements, dietary needs, social and leisure interests. Supporting risk assessments were also viewed and where there are any identified risks the recording should continue to be developed as to how these will be managed. All these documents had been reviewed. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 11 All service users are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Service users spoken were asked about access to a GP, chiropodist optician or a dentist. Not all had required these services, some they stated they had accessed these services. The AQAA detailed that medication policies and procedures are in place and the administration of medication was observed at lunchtime. Medication is stored in a locked cupboard and sample of the recording of medication administered was viewed. When PRN medication is to be administered the Manager stated that she gave verbal instructions to staff, but there should be written guidance for staff in place and the Manager stated this would be addressed. Where service users administer all or part of their medication this should be supported by a detailed risk assessment. Where medication is stored in a refrigerator the Manager agreed to ensure that this is kept securely. Staff confirmed, but the records were not viewed on this occasion, that a pharmacist regularly visits. Staff spoken with, who administer medication confirmed they had received medication training. All the service users feedback was that they felt that their medical care needs were met. Staff was observed to deliver care with dignity and respect. The three service users spoken with felt the care provided respected their privacy and dignity. All of the ten service users surveys stated they received the care and support they needed, and comments received were ‘kind, caring people,’ ‘when ever I need it the carer is there for me,’ ‘the carers are very kind,’ ‘they are kind and caring,’ ‘I get help when I want to go to the toilet,’ ‘the carers are extremely caring,’ ‘extremely caring everyone that works here,’ and ‘my carer always gives me a good shave when I ask her,’ ‘I am happy here,’ ‘I have been here for years and hopefully many more to come’ ‘ I like it here,’ ‘I like my home,’ ‘I am very happy here,’ and ‘I really like it here.’ Visitors commented, ‘the service users are well fed, well cared for by attentive staff, who go out of their way to ensure that the service users are happy,’ ‘the service users are well looked after. The meals are good and nicely served. The staff is caring and efficient and the atmosphere is one of a comfortable home’ and ‘the home has a pleasant atmosphere. Staff are very nice.’ Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities provided, but these should continue to be developed, service users are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA details an activities co-ordinator works in the home, who dedicates two hours twice a week for activities following discussion with the service users. Activities include bingo, exercise and sing-a-long sessions and visits to the local park for coffee and cake. External entertainers also visit the home. No activities were facilitated during the Inspection, but the service users were seen being consulted with about what activities they would like to participate in for the following day. The range and frequency that activities are provided should continue to be developed and detailed within the AQAA was that it is planned to facilitate more discussion groups for service users to join in and an Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 13 outdoor gardening area is planned. Eight of the service users surveys stated there are always activities arranged and two usually, and comments received were, ‘all activities I enjoy bingo, dancing and singing,’ ‘I like the bingo,’ ‘I like dancing and the singer, ‘ ‘I like to play bingo,’ ‘the singer is very good and I like the bingo,’ ‘I really like it when the singer comes,’ ‘all activities I enjoy,’ ‘great fun dancing, singing and playing bingo,’ and ‘I do not play bingo but like to dance.’ The three service users spoken with confirmed there was flexible visiting, that staff are very welcoming and they could see their relative/friend in private if they wished. All four relatives stated homes helps the service users to keep in touch, and one commented, ‘if applies I always get a phone call.’ The care and support provided was observed to enable service users where possible to exercise choice whilst at Charlesworth. The five service user files viewed and the three service users spoken with confirmed this. The cook works six days a week, but was not on duty during the Inspection with the Manager preparing the days lunch. A rotating menu is not in place, but the sample of records viewed evidenced that a varied diet is provided, which staff stated takes into account service users likes and dislikes. Special diets are catered for. The lunchtime meal was observed served in the dining room and staff were available to offer any assistance to service users if required. Lunch was fish and chips followed by cherry pie. There was no alternative recorded but staff and service users spoken with on the day confirmed that an alternative would be provided if required. Service users chose from a selection of choices for their evening meal. Records had been maintained of individual food consumption, to monitor that service users have had an adequate diet. The ten service users surveys stated they always likes the meals, ‘great choice,’ you get a nice choice,’ a lovely choice,’ I really like the food and the choices,’ plenty of choice,’ ‘plenty of choices,’ and ‘we have always very succulent meals. It is like eating in a good restaurant.’ Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse, but it must be ensured that these are followed to protect service users. EVIDENCE: The home has a complaints policy and procedure in place, which now details a twenty-eight day response time following receipt of a complaint and this was available to view in the home. The AQAA detailed that no complaints had been received since the last Inspection and the CSCI has not received any concerns in relation to Charlesworth. All of the service users and visitors knew who to speak to if they had any concerns and the service users spoken with during the Inspection confirmed that they would feel comfortable raising any concerns with staff. The AQAA detailed that there is a policy and procedure in place in relation to vulnerable adults and a whistle-blowing policy. Staff spoken with had an awareness of the policies and procedures. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 15 Staff recruitment procedures must ensure that no staff member is engaged to work in the home until a POVA First/CRB clearance check has been returned and references have been received. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 16 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, 25 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is decorated and furnished in a homely style and work is being completed to ensure that the standard of the environment continues to be improved so that service users are provided with an attractive and homely place to live. EVIDENCE: Service users live in a comfortable and homely environment the standard of décor, carpeting and furnishings is good. At the time of the Inspection the reception and corridor areas were being redecorated. The AQAA details that double glazing has been fitted and further improvements planned to the home over the next twelve months include new dining room tables and chairs and Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 17 the downstairs bathroom is to be refurbished and a bath with a chair lift/shower provided. Service users accommodation consists of fourteen single bedrooms and two double bedrooms. There are no en-suite facilities but there are communal bathroom facilities and toilet facilities provided throughout the home. Service users are able to bring in their own possessions plus small items of furniture and this helps to make rooms more personalised. A number of bedrooms viewed displayed service users individual styles and interests. The three service users spoken with confirmed there is adequate heating and hot water in the home. A passenger lift is available from the lower floor to the first floor. Bedrooms located at the top of the house would only be suitable for people who have reasonably good mobility. There is one lounge/dining area on the ground floor and is where the majority of the service users congregate during the day. The home has a pleasant rear garden and decking area at the rear of the home. The AQAA details that there is a policy in place for managing infection control. The home was clean and free from offensive odours at the time of the Inspection. One member of the housekeeping team spoken with was aware of procedures in place to control infection, had attended infection control and control of substances hazardous to health (coshh) but had not had any recent training/guidance update. This was discussed with the Manager, who stated that this was one area of training that it is proposed to provide an update for staff. The worker also stated there was good access to protective clothing. Feedback from the service users and relatives was that the home was fresh and clean. Nine service users surveys stated the home always clean and one usually and comments received were ‘the cleaner comes every day,’ ‘the cleaner is very good,’ they are always cleaning,’ ‘they always keep it spotless,’ ‘extremely clean,’ ‘they are always cleaning every day,’ ‘ we have a good cleaner,’ and ‘they are very clean.’ Recording was viewed of routine fire checks that had been carried out in the home. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 18 Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 19 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 and 30. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels was adequate during the day, but the night staffing provided should be kept under review to ensure that the care needs of the service users resident continue to be met. A robust recruitment procedure needs to be in place to ensure service users are in safe hands at all times. EVIDENCE: Staffing on the day was adequate to meet the number and care needs of the service users resident. Staff spoken with confirmed that two members of care staff are deployed to work in the home during the day and the Manager and deputy manager were also working in the home at the time of the Inspection. At night the home deploys one ‘waking night’ member of care staff. The night staffing provided should be kept under review to ensure that the care needs of the service users resident continue to be met. A full time cook and a cleaner are also employed. The ten service users surveys stated staff listen and act on what service users said and comments received were, ‘ very helpful,’ ‘always supportive,’ ‘they are always happy to spend more time with you,’ ‘they always spend time with Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 20 us,’ ‘always kind and helpful,’ ‘the carer always listens and gets what I have asked for,’ ‘they are always happy to sit and help when needed,’ and ‘the staff are always ready to help any of the service users when they need help.’ All ten also stated that staff are available when you need them and commented, ‘helpful and caring,’ ‘kind and caring,’ ‘very helpful,’ ‘if I need them they are there to help me,’ ‘they are always happy to help me,’ ‘if you need a care you only have to ask,’ and ‘there is always someone in the lounge and if I want to sit in my room to watch a programme on my TV I can use my call bell.’ The AQAA detailed that three of the eight care workers holds an NVQ Level 2 in care which equates to thirty-seven and a half percent of the care staff and a further three care staff are currently working towards this qualification. Also that one care worker is due to commence NVQ Level 3. A thorough recruitment process was not demonstrated to be in place. The documentation was viewed for three new members of staff, all of whom had been recruited since the last Inspection. Two members of staff had commenced working in the home prior to a satisfactory POVA First check having been received. One of these still did not have a POVA First check in place. None had evidence of two written references. This was discussed with the Manager who has stated that a robust recruitment procedure will be followed, so an Immediate requirement was not made on this occasion. The Manager has subsequently stated that a satisfactory check has now been received. The Manager was able to confirm that the remaining staff working in the home has had a Criminal Records Bureau (CRB) check. The Manager evidenced that induction training for new members of staff are in place and stated that this would be reviewed to ensure this meets the requirements of the General Skills for Care induction standards. One new member of care staff that had been recruited since the last inspection was spoken with who confirmed and they had received induction. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 21 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, 33, 35, 36, and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home benefits from a Manager who ensures an open, supportive, homely and caring environment. Quality assurance systems have been developed to enable ongoing feedback about the care provided in the home and the outcome from the quality assurance process will need to be published annually, and available to the CSCI, service users and their representatives, and other stakeholders. EVIDENCE: Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 22 The home is run in a very friendly and caring manner and it was evident that service users felt very comfortable approaching the Manager with any concerns or issues. The Owner/Manager has been running this home for a number of years and is supported by a deputy manager, who confirmed they had completed the Registered Managers Award and NVQ Level 4 in care. The Manager has stated it is her intention to put an application forward for the deputy manager to become the Registered Manager and that she will in turn become the deputy manager and this will enable her to spend more time with the service users instead of being involved with ‘the paperwork side’ of managing the home. There is a quality assurance plan in place. There are opportunities for service users/representatives and other visiting professionals to put forward their views about the care provided through service users forums and surveys. The outcome of the quality assurance had not been collated, but the Manager subsequently stated this been completed and would be available to view. The AQAA detailed that policies and procedures were in place, which had been reviewed. Service users maintain their own finances or are assisted by family members and friends/representatives. All staff spoken with and the sample records viewed confirmed that individual staff supervision occurs on a regular and ongoing basis and there were regular staff meetings. Staff spoken with and the sample records viewed detailed they had attended training in moving and handling and basic food hygiene training and spoke of good access to training opportunities. The Manager stated that two fully qualified first aiders work in the home. Not all care workers spoken with had received training/guidance in first aid. The AQAA details it is planned to develop the training over the next twelve months to provide more opportunities. This was discussed with the Manager who confirmed that first aid was an area it was planned to ensure staff has received training/guidance along with infection control and coshh training. The Manager stated there was a fire risk assessment in place, but that this was not available to view as an external agency has been commissioned and is in the process of reviewing fire procedures in the home Staff training records viewed and staff spoken with evidenced that staff have attended fire training as required and there were records of regular fire drills. There was some wedging open of doors during the morning of the Inspection, which was discussed with the Manager who stated this was being addressed by the purchase of further devices to hold open the doors. A detailed check of the environment had been completed and carried out and the AQAA detailed that the maintenance of equipment and services has been Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 23 carried out. There was no regular testing of the hot water temperatures at outlets accessed by service users to ensure these are being maintained at close to 43 º C. This was discussed from the Manager who agreed to seek advice from the Environmental Health Department and re-instate regular checks. So a Requirement has not been made on this occasion. Samples of accident records were viewed and were detailed. Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 24 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 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 That service users selfadministering medication are protected by the completion of a detailed individual risk assessment to protect service users. That a robust recruitment procedure is in place. This includes the receipt of two written references and a POVA First check has been received prior to staff working in the home to protect service users. Timescale for action 30/09/07 2. OP29 19(1)(b) 24/08/07 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 Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Charlesworth Rest Home DS0000014190.V345574.R01.S.doc Version 5.2 Page 27 - 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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