This inspection was carried out on 24th November 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.
CARE HOMES FOR OLDER PEOPLE
Charlesworth 37 Beaconsfield Villas Brighton East Sussex BN1 6HB Lead Inspector
Merle Blakeley Unannounced Inspection 24th November 2005 10:30 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 DS0000014190.V250426.R01.S.doc Version 5.0 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 DS0000014190.V250426.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Charlesworth 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 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 DS0000014190.V250426.R01.S.doc Version 5.0 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 1st June 2005 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 rooms provide en suite facilities. The home has a pleasant rear garden that residents enjoy during the warmer months. A 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 is located in a residential area of Brighton and is close to local transport, parks and other local amenities. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Unannounced Inspection was carried out over a period of three and a half hours on November 24th 2005. The inspection process included informal chats with several residents and joining them for lunch, a tour of the premises, document reading and talking to staff that were on duty. What the service does well: What has improved since the last inspection? What they could do better:
Medication records were found to have some errors and all staff must ensure that any medication that is administered must be signed for immediately after it is given. Documents as set out in Schedule 4 of the National Minimum Standards must be kept on site and be available for inspection at all times. Staffing files and residents finances were unable to be inspected as the owner/manager was away on holiday and had taken the keys to the safe with her and the staffing files were being kept at her own place of residence. Staff are required to receive a minimum of three paid training days a year and there were no records available to support that this training had occurred.
Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 6 Staff stated that several staff had attended some training days but it was also evident that there was staff that had not received any training in 2005. The home must ensure that all staff receive the minimum three paid days training. It is also recommended that when the owner/manager is away from the home that she appoints a deputy staff member to manage the home on her behalf. 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. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 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 DS0000014190.V250426.R01.S.doc Version 5.0 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 the following standard(s): 1&4 The home provides each resident with a service user guide and a statement of purpose. The home feels it is meeting the needs of its current residents. EVIDENCE: The home has produced a service users guide and statement of purpose, which provides residents with information about the home and how it is run. The home feels it is meeting the needs of current residents. Several residents were spoken to during the inspection and they all stated that they were very happy with the care they were receiving and felt the home was meeting their needs. There is one resident whose needs are changing and alternative care may need to be found in the future. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 9 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&9 Residents care plans are updated regularly. Reviews need to be carried out at least twice a year or more frequently if resident’s needs change. Several discrepancies were found in the medication records. EVIDENCE: Several care plans were viewed and they appeared to be up to date and relevant. Some care plans had been reviewed in November 2005, however it was not clear as to whether all the care plans had been reviewed at that time. All care plans need to be reviewed at least six-monthly and more frequently if residents needs are changing. Daily information is recorded into a diary and this information is later transferred into the main care plans. There does appear to be a certain amount of duplication in the information recorded and perhaps this could be simplified. Medication records were also viewed on the day and there were a number of discrepancies found. Although there was an explanation for these errors the owner/manager and staff must ensure that when medications are administered they are signed for immediately. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 10 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 & 15 Residents are offered activities during the week. Visitors are welcome in the home. Residents receive a well balanced diet in convivial surroundings. EVIDENCE: A number of activities are offered to residents and these include exercise classes and regular visits from an entertainer. A hairdresser and chiropodist also make regular visits to the home. Residents felt that they were offered enough activities and were able to participate if they wished. Visitors are welcome at most times of the day and they are able to stay for meals with residents if they wish. Residents stated that they enjoy their meals at Charlesworth and the inspector was able to share an enjoyable lunch with several of the residents. Lunchtimes are a very convivial part of the day in the home. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 11 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 The home has a complaints policy and procedure. EVIDENCE: The home has a written policy and procedure regarding complaints. The complaints log was viewed and there have been no complaints made to the home. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 12 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, 20, 21 & 26 The home is generally well maintained. Communal areas are located on the lower ground floor. There are sufficient baths and toilets. The home was found to be clean and tidy. EVIDENCE: The home is maintained to a good standard. A lift is available from the lower floors to the first floor and access to the top floor is via a flight of stairs, so these rooms would not be very suitable for persons who have mobility problems. The communal areas, which, consists of the lounge and dining room, are situated on the lower ground floor and these areas are used a lot by residents. The home has three bathrooms with two battery-operated bath chairs to assist residents. There are six toilets located throughout the home. None of the rooms have en suite facilities. On the day of inspection the home was found to be clean and tidy and free of any offensive odours. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 13 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, 29 & 30 The home employs a stable and caring staff team. Recruitment files were not available to be viewed. Staff are still required to receive a minimum of three paid days training each year. EVIDENCE: The home employs a very caring and stable staff team who provide continuity of care for residents. On the day of this unannounced inspection there were two senior care staff, one ancillary staff member and the cook on duty. A family member of the homeowners was also present and he was also able to assist with the inspection as the owner/manager was away on annual leave. Residents stated that the staff team were caring and friendly and provided them with a good level of care. The inspector was informed that the staff recruitment files were not available to be viewed during this inspection as the owner/manager had taken them home for safekeeping. It is important that staff confidentiality and privacy is maintained, however these files must remain on site and be available to be inspected at all times. When the owner/manager is not available a deputy manager should be in place to be able to provide and locate such documentation as requested. A requirement was made during the last inspection for the owner/manager to ensure that all staff receive a minimum of three paid days training each year. There was verbal confirmation that some staff had attended courses on food
Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 14 hygiene and adult protection, however there was no documentation available to confirm this. There appears to be staff members who have not received any training at all during 2005. A requirement will again be made for the home to provide the minimum training for all staff members. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 15 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): 34, 35, 36 & 38 There was confirmation that the home carries out all the necessary financial procedures. Resident’s finances could not be viewed during this inspection. Staff are not receiving formal recorded supervision sessions and annual appraisals. Fire doors are due to be fitted with magnetic closures. EVIDENCE: The home continues to be viable and suitable accounting procedures are carried out by the owner/manager. Several residents manage their own financial affairs and others have the assistance of family and friends to help them. The financial records of some of the residents were unable to be viewed at this time, as the owner had taken the keys to the safe with her. Residents were given additional funds to cover the two weeks the owner/manager would be away. This is not an ideal situation, as in an emergency access to the safe may be necessary. It would be recommended that a spare set of safe keys are left with a deputy manager or a senior staff member who would then be
Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 16 responsible for residents finances. Residents must be able to have reasonable access to their own personal money. Staff information was not available to be viewed but it was stated that staff are receiving supervision sessions but they are not being formally recorded. Supervision sessions must be recorded and carried out at least six times a year. Staff appraisals also need to be carried out on an annual basis. During the last inspection it was noted that several fire doors on the lower ground floor were being left wedged open to allow residents easier access through the doors. The home was required to provide magnetic closures for these doors so that they can close automatically should the fire alarm be activated. Although these closures were not in place there was paperwork available to indicate that the closures were to be installed the following week. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 17 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 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 2 2 X 3 Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 18 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 OP30 Regulation 18(c) Requirement That all staff receive a minimum of three paid training days per year. Previous Requirement That all medications are signed for by staff as soon as they are administered. That staffing records are always available to be viewed at each inspection. To ensure that when the owner/manager is not on the premises that there is a procedure in place for service users to be able to access their personal finances. That all staff receive formally recorded supervision sessions at least six times per year and that annual appraisals are also carried out. Timescale for action 31/01/06 2. 3. 4. OP9 OP37 OP35 13(2) Schedule 4 17(3)(b) 24/11/05 24/11/05 24/11/05 5. OP36 18(2) 31/01/06 Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 19 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 OP27 Good Practice Recommendations That the owner/manager considers appointing a deputy manager for when she is absent from the home. Charlesworth DS0000014190.V250426.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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