Inspection on 04/07/06 for Charlesworth Rest Home

This inspection was carried out on 4th July 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 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 24/08/07

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 37 Beaconsfield Villas Brighton East Sussex BN1 6HB Lead Inspector Merle Blakeley Unannounced Inspection 4th July 2006 10:00 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 DS0000014190.V292234.R01.S.doc Version 5.1 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.V292234.R01.S.doc Version 5.1 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.V292234.R01.S.doc Version 5.1 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 24th November 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. The current fees are £361.00 per week with additional charges for hairdressing, chiropody and newspapers. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out over a period of eight hours on 4th July 2006. As well as this site visit information was also gained from a preinspection questionnaire, feedback survey forms from residents, relatives and visiting professionals, informal talks with seven residents, three staff, the deputy manager and the owner/manager. The site visit consisted of a tour of the premises, looking at the particular needs of five residents, document reading, lunch with the residents and observing staff interactions with residents throughout the day. There are currently sixteen people residing in the home. What the service does well: What has improved since the last inspection? The home has addressed all the requirements that were made during the last inspection in November 2005. All staff are now receiving a minimum of three paid days training per year. Medications are now correctly signed for as soon as they are administered and the home has updated its medication policy and procedure. The deputy manager now holds keys to all locked confidential documentation when the owner/manager is not on site. Staff are now receiving annual appraisals and supervision sessions on a regular basis. The care plans continue to improve and they are much more informative and organised. The home has recently redecorated two bedrooms and purchased new armchairs and vertical blinds for the lounge area. Three staff have obtained the NVQ Level 2 and a further two staff are due to commence this training later in the year. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 6 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. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 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.V292234.R01.S.doc Version 5.1 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): 3 Standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Formal written assessments are not carried out. EVIDENCE: Prior to a resident moving into Charlesworth the home receives a written assessment from the placing authority. The owner/manager visits the prospective resident either in their home or in hospital to make her own assessment of whether the home can meet their needs. This assessment has not been written down formally in the past and the home will need to address this and produce a written assessment document. This written assessment will then form part of the persons care plan. The home needs to evidence that it can meet resident’s personal needs in all aspects of their lives. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 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, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are informative and up-to-date. Resident’s healthcare needs are being met. Medication is currently being appropriately administered. On the day residents were seen to be treated with respect and dignity. EVIDENCE: Five care plans were viewed during this visit and they were found to be informative and well organised. Reviews of care plans had been carried out in April 2006. Risk assessments are also reviewed on a quarterly basis and daily logs are maintained. The home is meeting the healthcare needs of the current residents. Residents are all registered with their own doctor and they have access to district nurses, CPN’s, chiropodist, dental services and opticians. The chiropodist visits the home on a six weekly basis and opticians carry out regular visits. Medication records were viewed and they were found to be in order. All staff have received the homes updated medication policy, which contains clear Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 10 guidelines of how medication must be administered and recorded. Four of the current staff members are booked to attend medication training soon. One of the residents self-medicates and there have been some concerns as to whether he can continue to manage this. The home will need to carry out frequent risk assessments to ensure that his medication continues to be well managed. The home has been in consultation with his family and local GP. During the day observations were made of how staff interact with residents and these observations were very positive. Staff were seen to treat residents in a respectful and friendly manner. Residents who were spoken to stated that they were felt very well cared for by the staff. The home has a friendly and caring atmosphere. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The home needs to provide a broader range of activities during the afternoon period. Residents are encouraged to maintain family links. Residents are able to exercise choice and control over their lives. The home provides a well-balanced diet, which is enjoyed by all the residents. EVIDENCE: A number of activities are offered to residents on a regular basis, however residents did state that they would like the opportunity to be involved in a broader range of activities particularly during the afternoon. Several stated that they missed the exercise classes. Unfortunately the lady who was taking these classes is no longer able to do this and the owner/manager has been looking for a replacement. Three of the residents are able to go out on their own independently and do this on a daily basis. Visitors are made very welcome in the home and some will stay and have lunch or supper with their relative. Residents are positively supported to maintain their links with family and friends. Some residents are able to visit their relatives whilst others have regular visitors coming into the home to see them. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 12 Residents were asked as to whether they felt they had choices in their lives and all stated that they felt they had. They can make choices in all aspects of their daily lives. They also felt that within reason they had control over some aspects of their lives. Staff are supportive and would help a resident if they had any concerns or problems to resolve. Charlesworth continues to provide very good quality meals. Residents spoke very highly of the meals the home provides and praised the cook for the ‘wonderful’ dinners and desserts she prepares. The inspector was able to enjoy a very nice lunch with some of the residents. Meals are prepared each day using fresh produce. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedure needs to contain additional information. The home has produced a suitable adult protection policy and procedure. EVIDENCE: The home has compiled a complaints policy and procedure, however it needs updating to state that the home will respond to all complaints within a 28-day period. The complaints file was viewed and there have been no complaints made to the home. The home has produced an adult protection policy and procedure. Both the deputy manager and most of the staff have attended training in the protection of vulnerable adults within the last year. There are no adult protection issues within the home. Staff recruitment procedures ensure that no staff member is engaged to work in the home until a CRB clearance check has been returned. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The environment is safe and well maintained. The home is kept clean and tidy with no offensive odours. EVIDENCE: Residents live in a safe, comfortable and homely environment. Communal areas are located on the lower ground floor and the home has recently purchased new armchairs for the lounge area and new vertical blinds. Later in the year the front of the building will have new windows installed. Resident’s bedrooms are comfortable and tastefully furnished. Residents are able to bring in their own possessions plus small items of furniture and this helps to make rooms more personalised. A 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. The home is well maintained and was found to be very clean and tidy on the day. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 15 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. The staff team provide a good level of care to residents. 30 of the staff are trained to NVQ Level 2. The homes recruitment practices meet the current standards. Staff are now receiving adequate training. EVIDENCE: The staff team have remained relatively stable since the last inspection and there are currently nine care staff employed in the home. A full time cook and a cleaner are also employed. Residents were asked about the care they received and all responded very positively. They all stated that the staff were very caring and friendly and looked after them well. The staff were seen to have a relaxed and caring relationship with the residents and it was evident that they were knowledgeable about each persons particular needs. There are currently three staff who have obtained the NVQ Level 2 qualification and there are a further two staff who are due to commence this training in August 2006. The deputy manager has commenced NVQ Level 4 training and will also obtain the Registered Managers Award in due course. The home carries out suitable recruitment procedures and the owner/manager is aware that all staff require two written references, a checkable work history, a returned CRB clearance check, a recent photo and proof of their identity and current address. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 16 During the last inspection the home was required to ensure that all staff receive a minimum of three paid training days per year and records show that this has been occurring. Staff have attended courses in medication, manual handling, adult protection and food hygiene. Two staff have also attended the TOPPS working in care induction course. Three remaining staff are booked to attend medication training and adult protection. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 17 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. The home is managed in a friendly and supportive manner. Resident feedback surveys need to be carried out more frequently. Resident’s finances are safeguarded. Overall the health & safety of the home is maintained. EVIDENCE: The home is run in a very friendly and caring manner and it was evident that residents felt very comfortable approaching the owner/manager with any concerns or issues. The owner/manager has been running this home for a number of years and it is her intention that the deputy manager will become the registered manager once he has completed the Registered Managers Award. The owner has decided that she will in turn become the deputy manager and this will enable her to spend more time with the residents instead of being involved with ‘the paperwork side’ of managing the home. Residents Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 18 spoke positively about the deputy manager and felt he was also very friendly and caring. The home has developed a quality assurance programme, which includes an annual development plan. A resident satisfaction survey has been carried out but this was some time ago and the home needs to ensure it is carried out at least twice a year. Feedback surveys also need to be sent out to relatives and visiting professionals such as doctors, nurses, chiropodist etc. This will enable the home to receive a much broader scope of feedback and will provide further information as to how well the home is performing. Written feedback was received from three relatives and two doctors prior to this inspection and all stated that they felt happy with the care the home was providing. The home maintains the finances of three residents and these were checked and found to be in order. The remaining residents maintain their own finances and are assisted by family members and friends. A health and safety check was made during this visit and it was noted that the fire extinguisher on the top floor needed to be mounted onto the wall. A door guard was required to be installed on the first floor corridor door above the stairs and this was done immediately. Fire drills are carried out and recorded with the last one being held in January 2006. Hot water temperatures, call bells and the fire alarm are checked weekly. The emergency lighting is checked monthly. During this visit the weather was particularly hot and residents were being provided with lots of additional fluids and extra fans to help them stay cool. Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 19 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Charlesworth DS0000014190.V292234.R01.S.doc Version 5.1 Page 20 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 OP3 Regulation 14(1) Requirement That the home produces a formal, written assessment tool that records prospective service users initial care needs. That service users are provided with a wider range of activities that suit their preferences and abilities. That the complaints policy and procedure includes a 28-day response time. That the quality assurance programme includes gaining feedback from relatives and visiting professionals. Timescale for action 31/08/06 2 OP12 16(2)(m) 31/08/06 3 4 OP16 OP33 22 24 31/08/06 31/10/06 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 DS0000014190.V292234.R01.S.doc Version 5.1 Page 21 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 © 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 DS0000014190.V292234.R01.S.doc Version 5.1 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!